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TECHNIC 


OF  THE 


CARREL  METHOD 


J,  DUMAS  6?  ANNE  GARREt 


tRX>V3\         _D 

Columbia  ?Hntoer*tt|> 
i  n  tfje  Citp  of  Jleto  gov  k 

College  of  îBfjpôtcians  anb  âutrgeonsi 


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TECHNIC  OF 
CARREL  METHOD 


TECHNIC  OF 

The  Irrigation  Treatment  of  Wounds 

BY  THE 

CARREL  METHOD 

BY 
J.  DUMAS  &  ANNE  CARREL 


AUTHORIZED  TRANSLATION 
BY  ADRIAN  V.   S.  LAMBERT,  M.  D. 

Acting  Professor  of  Surgery  in  the  Collage  of  Physicians  and  Surgeons 
(Columbia  University)  New  York 

With  an  Introduction  by 
W.  W.  KEEN,  M.D.,  L.L.D.,  F.R.C.S.  (HON.) 


PAUL  B.  HOEBER 

NEW  YORK 


37 

Copyright,  191 7, 
By  Paul  B.  Hoeber 


Published,  November,  iqi? 


mil  1  i^ 

JT)  St) 


Printed  in  the  United  States  of  Amerfca 


Errata 


The  words  calcium  chloride  have  been  used  throughout  the 
book  in  place  of  the  words  chloride  of  lime  or  bleaching  powder. 
It  is  suggested  that  the  words  chloride  of  lime  or  bleaching 
powder  be  substituted  in  each  instance.  This  change  should  be 
noted  on  page  56,  lines  5, 10, 13, 16;  page  57,  line  16;  page  58, 
lines  12, 14, 22;  page  59,  line  3  and  in  table  ;  page  60,  lines  7, 9, 
19  ;  page  61,  line  20  ;  page  80,  line  12. 


INTRODUCTION 

Alexis  Carrel's  genius  has  been  shown 
in  many  remarkable  ways  and  has  already 
~eceived  the  hall-mark  of  a  Nobel  prize. 

But  now  he  has  done  a  still  greater 
jractical  service  to  humanity  in  the  new 
^nd  wonderfully  successful  technic  in 
treating  war  wounds  by  means  of  Dakin's 
Solution.  A  colleague,  M.  le  Dr.  J. 
Dumas,  and  Dr.  Carrel's  devoted  and  tal- 
ented wife — truly  a  helpmate,  who  has 
Ven  so  valiant  an  assistant  in  all  his  re- 
earches  both  in  this  country  and  in  France 
— have  amplified  the  details  of  this  treat- 
ment in  a  small  brochure  to  which,  in  its 
English  translation,  it  is  a  genuine  pleas- 
ure for  me  at  the  request  of  the  publisher 
to  furnish  this  brief  introductory  note. 
Every  surgeon  in  the  various  military  and 
naval  forces  and  also  those  in  civil  life 
who  have  to  do  with  industrial  and  other 

5 


2  (V 


6  INTRODUCTION 

accidental  wounds  should  know  this  tech- 
nic  by  heart  and  practice  it  with  exactness. 
They  will  be  rewarded  by  a  most  gratify- 
ing success. 

Wiluam  W.  Keen, 

Philadelphia,  November  19 17. 


PREFACE 

So  much  interest  has  centered  about 
the  method  introduced  by  Dr.  Carrel  for 
the  treatment  of  war  wounds  that  any 
book  embodying  his  ideas  is  certain  to  be 
of  service.  This  small  book  was  written 
by  Madame  Carrel,  who  has  worked  at 
Compiégne  and  become  a  most  proficient 
member  of  that  highly  trained  and  techni- 
cally skilled  staff.  It  was  written  pri- 
marily for  the  information  of  nurses  so 
that  they  might  have  a  clear,  short  account 
of  the  various  details  of  the  technic,  and 
an  accurate  description  of  the  apparatus 
used  in  carrying  it  out.  The  book  in  no 
way  supplants  the  more  complete  ac- 
count written  by  Dr.  Carrel,  The  Treat- 
ment of  Infected  Wounds*  An  effort 
has  been  made  to  keep  it  simple  and  direct 

*  Published  by  Paul  B.  Hoeber,  New  York. 

7 


8  PREFACE 

so  that  it  might  serve  as  a  guide  for  those 
wishing  to  become  proficient  assistants. 
It  is,  therefore,  shorn  of  all  theoretical 
considerations  which  might  be  confusing 
or  be  a  subject  of  controversy. 

Perhaps  this  is  not  the  place  to  sound 
the  praises  of  the  method,  but  I  cannot  re- 
frain, even  at  the  risk  of  being  somewhat 
out  of  order,  from  bearing  witness  to  the 
immense  value  which  the  treatment  has, 
not  only  in  the  wounds  of  war  but  in  the 
treatment  of  pyogenic  infections  in  civil 
practice. 

This  is  a  fairly  literal  translation  of  the 
first  portion  of  the  book,  with  such  few 
additions  as  seemed  wise  in  view  of  some 
of  the  latest  improvements  now  being  em- 
ployed by  Dr.  Carrel.  The  appendices 
have  been  translated  into  technical  Eng- 
lish which  gives  strictly  the  content  and, 
for  English  readers,  will  prove  easier 
reading  and  less  cumbersome  than  a  closer 
following  of  the  original  French  text. 
For  the  benefit  of  English  speaking  read- 
ers who  may  proceed  to  France,  a  short 


PREFACE  9 

glossary  of  French  terms  employed  for 
designating  the  various  elements  of  the 
apparatus  has  been  appended. 

In  this  book  no  attempt  has  been  made 
to  teach  surgery  or  to  explain  how  and  in 
what  cases  the  treatment  is  employed.  If 
it  leads  any  to  employ  correctly  the  latest 
tool  of  our  art  it  will  have  amply  justified 
its  publication. 

Adrian  V.  S.  Lambert. 

New  York,  November  19 17. 


CONTENTS 


PAGE 


Introduction  by  William  W.  Keen, 
M.D 5 

Preface 7 

I  Materials  Used  in  the  Dressing    .     15 

II  Preliminary  Remarks  of  the  Mi- 
croscopical Examination  of  the 
Wound  Secretions 25 

III  The  Dressing 26 

IV  The  Irrigating  Apparatus    ...     30 

V  Setting  Up  the  Irrigating  Appara- 
tus . 42 

VI  The  Technic  of  Irrigation        .     .     47 

VII  Appendices — 

(1)  The  Preparation  of  Da- 
kin's  Solution     ....     55 

(2)  The  Microscopical  Exam- 
ination of  War  Wounds  by 
the  Carrel  Method     .     .     63 

VIII  Glossary 79 

IX  Index       . 83 


LIST  OF  PLATES 

PLATE  PAGE 

I  Various  Sizes  of  Instillation  Tubes      .     17 
II  Covered  Instillation  Tubes        .      .      .19 

III  Distribution  or  Instillation  Tubes  Cov- 

ered with  Turkish  Toweling  and 
Provided  with  Guy  Ropes  for  Fix- 
ation at  Edge  of  Wound  .      .      .      .     21 

IV  Irrigation    Apparatus    Showing    Sup- 

porting Stand  with  Flask  in  Place   .     31 

V  Conducting  and  Instillation  Tubes       .     33 

VI  Enlargement  of  a  Portion  of  the  Ap- 
paratus Shown  in  Plate  IV    .      .      .     35 

VII  Glass  Conducting  Connector  and  Glass 

Distributors 39 

VIII  Supporting  Stand 43 

IX  Detail  of  the  Adjustable  Parts  of  the 

Supporting  Stand 45 

X  Pinchcock  and  Safety-pin     ....     49 

XI  Graphic  Record  of  Bacterial  Count      .     75 


TECHNIC  OF  THE  IRRIGATION 

TREATMENT  OF  WOUNDS  BY 

THE  CARREL  METHOD 

The  sterilization  of  wounds  by  repeated 
irrigations  with  a  solution  of  hypochlor- 
ite of  sodium,  called  Dakin's  Solution  (see 
Appendix  I)  requires  the  use  of  spe- 
cial, but  extremely  simple,  apparatus  and 
the  application  of  dressings  which  assure 
the  prolonged  contact  of  the  antiseptic 
with  all  portions  of  the  wound. 

MATERIALS   USED   IN   THE  DRESSINGS 

I.  Distributing  or  "Instillation"  Tubes 
(Tubes  distributeurs). — These  are  rubber 
drainage  tubes  No.  16  French  (4  mm.  in- 
ternal diameter,  the  wall  1  mm.  thick),  0.3 
to  0.5  m.  long.  They  are  of  two  varieties: 

(a)  Simple  or  non-perforated  distribut- 
ing tubes  in  which  the  ends  are  open,  and 

15 


i6         IRRIGATION  OF  WOUNDS 

half  a  centimeter  from  one  end  a  large  lat- 
eral opening  is  made  (Plate  I). 

(b)  Perforated  distributing  tubes 
which  have  one  end  closed  by  being  tied 
with  a  linen  thread,  and  whose  walls  are 
perforated  from  this  closed  extremity  for 
a  distance  of  5,  10,  15,  20  cm.  by  holes  1/rm 
1  mm.  in  diameter,  1  cm.  apart.  These 
are  spoken  of  as  5,  10,  15  or  20  cm.  tubes. 

The  rôle  of  these  tubes  consists  in  con- 
veying the  antiseptic  to  all  recesses  of  the 
wound.  The  portion  of  these  tubes  which 
is  perforated  with  holes  is  often  covered 
with  Turkish  toweling.  This  should  be 
firmly  attached  to  the  tube  so  that  it  can- 
not be  left  in  the  wound  on  the  removal 
of  the  tube.  These  tubes  covered  thus  are 
used  on  superficial  wounds  where  the  fluid 
must  be  spread  over  a  flat  surface  or  in 
wounds  with  dependent  openings  where 
the  distribution  of  the  fluid  is  difficult. 
Threads  are  left  long  at  the  ends  of  the 
toweling,  which  serve  as  guy  ropes  to 
steady  the  tube  (Plates  II  and  III).  They 
are  fastened  to  the  skin  with  small  pieces 


PLATE  I 


Various   Sizes  of  Instillation.  Tubes 
Tubes  5,  io,  15,  and  20  cm.  in  perforated  length  ;  also  sim- 
ple and  loop  tubes. 


PLATE  II 


A  B 

Covered  Instillation  Tubes 

A. — Covered  with  Turkish  toweling. 
B. — Cross  section  of  covered  tube. 


PLATE  III 


Distribution  or  Instillation  Tubes  Covered  with  Turkish  Towel- 
ing and  Provided  with  Guy  Threads  for  Fixation  at  Edge 
of  Wound 


MATERIALS  FOR  DRESSING        23 

of  adhesive  plaster  to  prevent  their  shifting. 

2.  Tampons  and  Compresses  of  Gauze. 
— These  do  not  differ  in  any  particular 
from  similar  articles  usually  used  by  all 
surgeons. 

3.  Cotton  Pads. — These  are  of  four 
sizes  measuring  0.25  by  0.14,  0.33  by  0.22, 
0.53  by  0.33,  1. 10  by  0.45  m.  They  consist 
of  a  layer  of  non-absorbent  cotton  and  a 
layer  of  absorbent  cotton  (except  that  the 
small  ones  are  composed  of  absorbent  cot- 
ton only)  wrapped  together  in  a  single 
thickness  of  gauze  which  should  be  folded 
carefully  back  over  the  absorbent  cotton 
completely  covering  it  in  its  entire  extent. 

All  these  materials  should  be  carefully 
sterilized  as  follows  : 

(a)  The  distributing  tubes  are  sterilized 
in  the  autoclave  at  1200  C.  for  twenty 
minutes  in  large  glass  test  tubes,  closed 
with  cotton  stoppers,  in  which  they  are  pre- 
served sterile  until  used. 

(b)  The  tampons,  compresses  and  cot- 
ton pads  are  sterilized  for  45  minutes  in 
the  autoclave  at  1340  C.  in  large  metal 


24         IRRIGATION  OF  WOUNDS 

boxes.  If  one  does  not  possess  enough  or 
sufficiently  large  boxes  for  sterilizing  the 
larger  pads  it  would  be  well  to  place  them 
in  the  autoclave  each  wrapped  separately 
in  a  piece  of  linen  or  white  paper. 

4.  Sterile  Vaseline  Compresses. — Their 
use  prevents  or  diminishes  the  irritant  ac- 
tion which  the  antiseptic  has  on  the  skin 
of  certain  people  in  the  region  of  the 
wounds  treated  by  irrigation.  These  vase- 
line compresses  are  prepared  in  the  follow- 
ing manner  :  A  number  of  pieces  of  gauze 
are  cut  measuring  about  6  by  12  cm.  A 
layer  of  white  vaseline  is  spread  on  one  of 
the  surfaces  of  each  with  a  spatula,  and 
the  squares  are  then  packed  one  above  the 
other  in  air-tight  metal  containers.  The 
containers  are  placed  in  the  hot  air  steril- 
izer, absolutely  horizontal  so  that  the 
liquefied  vaseline  cannot  run  out,  and  are 
sterilized  for  thirty  minutes  at  1300  C. 

5.  Articles  to  Keep  the  Dressings  in 
Place. — There  should  be  on  hand  to  steady 
the  dressing  and  hold  it  in  place  the  fol- 
lowing: 


MICROSCOPICAL  EXAMINATION    25 

(a)  Strips  of  unstarched  gauze; 

(b)  Flannel  binders  (so-called  many- 
tailed  bandage)  ; 

(c)  Safety-pins  of  different  sizes; 

(d)  Adhesive  plaster. 

I.      PRELIMINARY  REMARKS   ON  THE  PUR- 
POSE OF  THE  MICROSCOPICAL  EXAMI- 
NATION OF  THE  WOUND  SECRETIONS 

We  are  to  suppose  that  the  wound  which 
is  to  be  subjected  to  our  treatment  has  al- 
ready had  previous  care  :  tissue  fragments 
and  foreign  bodies  have  been  removed 
several  days  previously,  the  wound  has 
been  carefully  explored  and  cleansed, 
and  all  parts  of  it  have  been  made  readily 
accessible.  Before  commencing  the  dress- 
ing a  preliminary  microscopical  examina- 
tion of  the  wound  secretions  is  necessary, 
in  order  to  determine  the  degree  of  infec- 
tion. This  examination  has  to  be  repeated 
every  day  in  order  to  follow  the  progress 
of  disinfection,  and  to  determine  the  mo- 
ment when  this  disinfection  is  sufficient  to 


26         IRRIGATION  OF  WOUNDS 

allow  the  closure  of  the  wound  without 
danger  (see  Appendix  II). 

ii.     the:  dressing 

The  preliminary  microscopical  exami- 
nation having  been  made,  the  surgeon  is 
ready  to  draw  on  his  rubber  gloves  *  and 
to  do  the  dressing. 

The  nurse  who  is  assisting  must  have 
on  her  dressing  tray,  besides  tubes,  tam- 
pons, cotton  pads,  vaselined  compresses 
and  the  articles  necessary  for  fixing  the 
dressing: 

(a)  A  few  sterile  forceps  (Kocher's 
without  teeth)  ; 

(b)  Several  pairs  of  sterile  scissors; 

(c)  Sterile  basins; 

(d)  Dakin's  Solution. 

i.  The  nurse  should  seize  and  hand  to 
the  surgeon  all  the  sterile  things  which 

*  The  rubber  gloves  are  used  for  the  protection 
of  the  surgeon.  They  are  not  sterile  and  are  not 
changed  for  each  case  but  are  worn  during  the 
entire  period  while  the  surgeon  does  several 
dressings. 


THE  DRESSING  27 

he  may  require,  using  for  this  purpose  a 
pair  of  large  strong  forceps,  thus  avoid- 
ing any  possible  contamination. 

The  nurse  first  hands  two  sterile  for- 
ceps to  the  surgeon  with  which  he  is  to 
handle  the  sterile  dressings,  and  place 
them  on  the  wound  without  ever  touching 
them  with  his  hands.  These  forceps  are 
changed  not  only  for  dressing  each  pa- 
tient, but  very  often  also  for  dressing  dif- 
ferent wounds  in  the  same  patient,  when 
these  have  different  degrees  of  infection. 

2.  The  nurse  should  then  hand  the  sur- 
geon as  he  calls  for  them  : 

(a)  Tampons  or  compresses  moistened 
with  Dakin's  Solution,  if  the  condition  of 
the  wound  requires  cleansing  ;  * 

(b)  Scissors,  if  there  is  any  necrotic 
tissue  to  be  excised  ; 

(c)  One  or  more  simple  distributing 
tubes  or  those  perforated  for  5,  10,  15,  or 
20  cm.,  depending  upon  the  size  and  shape 

*  The  wound  may  be  cleansed  with  a  solution 
of  neutral  sodium  oleate  which  is  not  irritating  to 
the  skin  or  wound. 


28  IRRIGATION  OF  WOUNDS 

of  the  wound,  the  amount  of  infection  or 
the  presence  or  absence  of  necrotic  tissue 
on  its  surface.  Some  of  the  tubes  are 
placed  in  the  deep  parts  and  pockets  of 
the  wound  and  underneath  skin  flaps, 
while  others  are  laid  on  the  superficial  por- 
tion in  such  a  way  that  the  perforations 
rest  on  the  necrotic  tissues  or  the  most 
infected  areas.  These  superficial  tubes 
are  held  in  place  by  means  of  strips  of  ad- 
hesive plaster  attached  to  the  skin  several 
centimeters  away  from  the  margins  of  the 
wounds. 

(d)  Gauze  compresses  moistened  with 
Dakin's  Solution  in  a  sterile  basin  are  used 
to  keep  the  tubes  in  place,  to  close  off  cer- 
tain portions  of  the  wound,  to  dilate  fistu- 
lous tracts,  to  lift  up  a  flap,  in  short  to 
cover  or  line  the  entire  wound.  When 
these  compresses  have  been  inserted  in 
the  wound,  they  absorb  a  considerable 
amount  of  irrigating  fluid  which  is  thus 
distributed  and  kept  in  contact  with  all 
recesses  of  the  wound. 

(e)  Vaselined  compresses,  which  are  to 


THE  DRESSING  29 

be  used  around  the  wound  on  the  skin 
that  is  exposed  to  the  action  of  any  of  the 
antiseptic  solution  which  leaks  out  of  the 
dressings.  * 

Finally,  the  dressing  is  completed  by 
covering  all  the  compresses  with  a  cotton 
pad  of  correct  size  so  placed  that  the  ab- 
sorbent cotton  side  lies  toward  the  wound. 
When  the  dressing  has  been  applied  to  an 
extremity,  the  cotton  pad  should  be  large 
enough  to  encircle  the  limb. 

The  cotton  pads  are  best  held  in  place 
by  safety-pins,  if  there  is  no  danger  of 
the  dressing  being  displaced.  If  band- 
age is  used,  it  should  be  loosely  wound  so 
as  not  to  compress  the  distributing  tubes. 
These  tubes  should  project  several  centi- 
meters beyond  the  dressings. 

A  many-tailed  flannel  binder  is  often 
preferable  to  the  roller  bandage. 

3.  The  adjustment  of  this  binder  avoids 
moving  the  wounded  limb,  which  is  al- 
*  In  place  of  the  vaseline  compresses  the  skin 
surrounding  the  wound  may  be  covered  with  vas- 
eline smeared  on  with  a  spatula. 


30  IRRIGATION  OF  WOUNDS 

ways  troublesome  during  the  application 
of  a  roller  bandage,  and  allows  the  em- 
ployment of  safety-pins. 

III.      THD   IRRIGATING  APPARATUS 

The  irrigating  apparatus  (Plate  IV)  is 
composed  of: 

i.  The  Flask  or  Reservoir  (Ampoule) 
(see  Plate  IV)  of  glass,  with  a  capacity  of 
one  liter  (1.75  pints);  it  is  the  container 
for  the  antiseptic  fluid.  The  flask  has  a 
short  neck  and  a  funnel-shaped  opening 
at  its  upper  end  for  the  introduction  of 
the  fluid.  The  lower  end  is  tubular  with  an 
internal  diameter  of  7  mm.,  over  which 
the  conducting  tube  fits. 

2.  Conducting  Tube  (Tube  adducteur) 
(Plate  V,  CT  and  Plate  VI,  CT).— 
Through  this  rubber  tube,  which  has  an 
internal  diameter  of  7  mm.,  the  fluid  runs 
from  the  reservoir  to  the  tubes  in  the 
wound. 

If  the  dressing  consists  of  a  single  tube 
or  of  two,  three,  or  four  distributing  or 
"instillation"  tubes   (Plate  IV,  Plate  V, 


PLATE  IV 


Irrigation  Apparatus,  Showing  Supporting  Stand  with 
Flask  in  Place 
Attached   are   main   conducting  tube,   glass   conductor, 
secondary  conducting  tubes,  glass  distributors  and  instil- 
lation tubes. 


PLATE  V 


Conducting  and  Instillation  Tubes 
A. — Conducting  tube,  CT,  shown  connected  with  distribution  or  instil- 
lation tubes,  IT,  by  a  glass  distributor,  C,  with  four  outlets. 

B. — Loop  instillation  tube  connected  up  with  a  glass  distributor. 


PLATE  VI 


Enlargement  of  a   Portion  of  the  Apparatus   Shown  in 

Plate  IV 

CT,  main  conducting  tube  ;  A,  glass  conducting  connector  ; 
SCT,  secondary  conducting  tubes  ;  B,  C,  glass  distributors  ;  IT, 
instillation  tubes  ;  S,  simple  instillation  tube  ;  TT,  tube  covered 
with  turkish  toweling  with  guy  threads;  P,  pinchcock. 


IRRIGATING  APPARATUS  37 

Plate  VI,  IT)  the  ends  of  which  are  near 
together  where  they  emerge  from  the 
dressing,  the  conducting  tube  for  a  great 
part  of  its  course  from  reservoir  to 
dressing  should  be  long  enough  to  rest 
on  the  bed  without  being  stretched.  If  it 
is  too  short  it  is  always  easy  to  lengthen 
it  by  joining  on  a  new  section  of  rubber 
tubing  of  proper  length. 

The  primary  rubber  conducting  tube 
(Plate  VI,  CT)  can  be  connected  with  two 
secondary  tubes  (secondary  rubber  con- 
ducting tubes,  Plate  VI,  SCT),  so  that  it  is 
possible  to  irrigate  from  a  single  flask  a 
wound  which  contains  more  than  four  rub- 
ber distributing  or  "instillation"  tubes,  or 
two  wounds  which  are  near  each  other. 

This  is  accomplished  by  means  of  con- 
nections which  we  call  glass  conducting 
connectors.     (Plate  VI,  A.) 

3.  Glass  Conducting  Connectors  (Rac- 
cords adducteurs)  (Plate  VII). — These 
are  of  two  kinds,  straight  glass  cylindrical 
connectors  ;  and  others  of  the  same  diame- 


38         IRRIGATION  OF  WOUNDS 

ter,  but  bifurcated  into  a  "Y"  (Plate  VII, 
A). 

4.  A  Pinchcock  or  Clamp  (Pince  de 
Mohr  à  rassort)  (Plate  X,  Fig.  A).— 
This  should  be  placed  on  the  primary  rub- 
ber conducting  tube  (Plates  IV;  VI,  P)  to 
prevent  the  liquid  from  escaping  in  the  in- 
tervals between  irrigations. 

5.  Glass  Distributors  (Raccords  dis- 
tributeurs) (Plate  VII,  B,  C,  D).— These 
are  of  glass  and  connect  the  rubber  con- 
ducting tubes  with  the  rubber  distributing 
tubes.  (Plate  VC;  Plate  VI  B,  C.)  If 
there  is  only  one  distributing  tube  in  the 
wound,  then  a  single  straight  glass  distrib- 
utor is  used;  in  other  cases  a  two,  three,  or 
four  branched  glass  distributor  is  required 
when  two,  three,  or  four  distributing  tubes 
are  employed.  The  glass  distributors  are 
called  simple  (Plate  VII,  D),  forked(Plate 
VII,  B),  trident,  and  comb  shaped  (Plate 
VII,  C),  according  to  the  number  of 
branches.  The  internal  diameter  of  the  end 
of  these  distributors  which  is  to  join  the 


PLATE  VII 


Glass  Conducting  Connector  and  Glass  Distributors 
Glass  connector,  A,  is  7  mm.  diameter  throughout;  glass  distribu- 
tors (B,  C,  D)  have  a  diameter  of  7  mm.  at  the  larger  end  and  4  mm.  at 
the  smaller.     E  is  a  small  connecting  tube  of  4  mm.  diameter. 


; 


•  ni 


IRRIGATING  APPARATUS  41 

rubber  conducting  tube  should  be  7  mm;; 
the  other  ends  over  which  the  rubber  dis- 
tributing tubes  fit  should  have  an  internal 
diameter  of  only  4  mm.  (see  Plate  VII) . 

6.  Small  Straight  Glass  Distributing 
Tubes  (Petits  raccords  droits)  (Plate 
VII,  E). — Sometimes  the  ends  of  the  rub- 
ber distributing  tubes  do  not  project  far 
enough  outside  of  the  dressing  and  can- 
not, therefore,  be  readily  connected  to  the 
glass  distributors.  By  means  of  a  small 
glass  tube  with  an  inner  diameter  of  4  mm. 
and  length  of  0.025,  it  is  a  simple  matter 
to  attach  an  additional  piece  of  rubber  tub- 
ing of  the  same  diameter  as  the  rubber  dis- 
tributing tube. 

The  entire  apparatus  should  be  washed 
:n  warm  soap-suds  and  rinsed  in  boiled 

iter.  The  flask  should  be  washed  out 
\  ith  Dakin's  Solution  and  the  glass  con- 
necting pieces  and  rubber  tubing  immersed 
for  two  hours  in  the  same  solution.  If  the 
apparatus  has  not  been  contaminated,  no 
further  sterilization  is  necessary. 


42         IRRIGATION  OF  WOUNDS 

IV.      SETTING    UP   OF   THE    IRRIGATING 
APPARATUS 

The  flask  (see  Plate  IV)  containing 
the  antiseptic  solution  is  closed  at  its 
upper  end  with  a  plug  of  sterile  cotton. 
The  rubber  conducting  tube,  to  which  the 
spring-clamp  is  attached,  is  connected  to 
its  lower  end  (Plate  IV)  and  provided 
with  a  simple  or  Y-shaped  glass  conduct- 
ing connector  (Plate  VI,  A).  This  flask 
is  suspended  at  a  height  of  0.60  to  0.80  m. 
above  the  level  of  the  injured  person  by 
means  of  a  stand  attached  to  one  of  the 
bed-posts.  We  have  designed  a  stand  with 
a  sliding  carrier,  which  holds  the  flask  and 
permits  of  an  adjustment  to  different 
levels  (Plates  VIII  and  IX). 

All  that  remains  to  be  done  is  to  connect 
the  lower  end  of  the  rubber  conducting 
tube  or  tubes  with  the  rubber  distribut- 
ing tubes  which  project  from  the  dress- 
ing (Plate  V,  C;  Plate  VI,  B  and  C),  and 
the  irrigation  can  be  begun. 

This  connection  is  made  by  means  of 


PLATE  VIII 


Supporting  Stand 

The   slot   makes   it  possible  to  ad- 
just the  flask  holder  at  suitable  levels. 


PLATE  IX 


<~2'/a--> 


E3E 


ES 


< 5" -> 


•/2*->a 


<-— 5»r. _> 


\/ 


<, 5n > 

Detail  or  the  Adjustable  Parts  of  the  Supporting 

Stand, 
The  grooved  slot  provides  for  lifting  the  upper  rack 
so  that  the  flask  may  be  inserted. 


TECHNIC  OF  IRRIGATION  47 

the  glass  distributors  (Plate  VII,  B,  C, 
D).  The  latter  are  selected  according  to 
the  number  and  arrangement  of  the  rub- 
ber distributing  tubes;  their  larger  end  is 
slipped  into  the  secondary  rubber  conduct- 
ing tube,  while  their  small  ends  are  con- 
nected to  the  rubber  distributing  tubes 
(see  details  in  Plate  V  and  Plate  VI). 

To  prevent  slipping  of  the  tubes  a  large 
safety-pin  (Plate  VI  and  Plate  X,  Fig.  B) 
should  be  fastened  to  the  cotton  pads  of 
the  dressing  and  should  enclose  between 
its  branches  the  large  end  of  the  glass  dis- 
tributor covered  by  the  rubber  conducting 
tube.  A  safety-pin  should  also  fasten  the 
glass  conducting  connector. 

V.      TH3  TECHNIC  OF   IRRIGATION 

These  preliminaries  having  been  com- 
pleted, the  procedure  is  begun  by  which 
an  amount  of  fluid  is  carried  into  the 
dressings  sufficient  to  maintain  a  continu- 
ous action  of  the  antiseptic.  Every  two 
hours,  night  and  day,  the  pinchcock  on 
the  rubber  conducting  tube  is  opened,  for 


48         IRRIGATION  OF  WOUNDS 

a  variable  length  of  time,  depending  on 
the  gravity  and  nature  of  the  wound. 

Ordinarily,  the  pinchcock  must  be 
opened  for  from  one  half  a  second  to  three 
seconds  in  order  to  allow  enough  antisep- 
tic solution  to  flow  out  to  soak  the  dress- 
ings and  fill  the  wound.  This  is  learned 
after  a  little  experience.  It  is  a  good  plan 
to  determine  the  time  that  the  solution 
shall  be  allowed  to  flow  by  doing  the  first 
irrigation  of  a  wound  while  it  is  still  un- 
covered by  the  outside  dressing. 

At  each  irrigation,  one  must  be  certain 
that  the  fluid  flows  freely,  if  this  is  not  the 
case,  the  cause  of  the  obstruction  must 
be  sought.  The  rubber  conducting  tube 
should  be  examined  from  its  point  of  con- 
nection with  the  flask  to  the  glass  distribu- 
tors, and  any  compression  relieved  and 
bends  straightened  out.  The  exposed  parts 
of  the  rubber  distributing  tubes  are  also 
examined.  If  all  these  are  in  good  order, 
the  trouble  must  be  located  in  the  interior 
of  the  dressings,  and  the  surgeon  should 
therefore  be  notified.  When  the  distribut- 


PLATE  X 


B 

PlNCHCOCK    AND    SAFETY-PIN 

À. — Enlarged  view  of  pinchcock  used  to  regulate  the 
flow  of  the  antiseptic  solution. 

B. — Enlarged  view  of  safety-pin  showing  method  of 
holding  tubes  and  glass  distributors  in  place. 


TECHNIC  OF  IRRIGATION  51 

ing  tubes  are  not  changed  at  every  dress- 
ing, it  is  absolutely  necessary  to  be  certain 
of  the  permeability  of  the  tubes  by  inject- 
ing some  solution  through  them  with  a 
syringe. 

As  the  irrigating  fluid  often  oozes  out 
of  the  dressings,  rubber  sheeting  covered 
with  a  bed-pad  should  be  placed  under  the 
patient,  so  that  the  bedding  shall  not  be 
soaked.  This  bed-pad  can  be  changed  as 
often  as  it  is  necessary. 


APPENDICES 


APPENDIX  I 

PREPARATION    OF    DARIN'S    SOLUTION 
(daufresne's  T£CHNIC) 

D akin' s  Fluid  is  a  solution  of  sodium 
hypochlorite  for  surgical  use.  Numerous 
experiments  and  a  prolonged  practical  ex- 
perience with  the  solution  have  shown  that 
it  must  have  the  following  properties  : 

(a)  The  fluid  must  not  contain  caustic 
alkali.  In  order  to  use  a  hypochlorite  solu- 
tion for  the  treatment  of  wounds,  it  must 
be  free  from  traces  of  caustic  soda  ;  Javel 
water,  Labarraque  Solution  and  all  solu- 
tions not  prepared  in  the  manner  we  shall 
describe,  cannot,  therefore,  be  used. 

(b)  The  strength  of  the  hypochlorite 
solution  must  be  absolutely  fixed  between 
0.45  and  0.5  per  cent.  Solutions  that  are 
weaker  than  0.45  per  cent,  are  too  weak; 
those  that  contain  more  than  0.5  per  cent. 

55 


56  IRRIGATION  OF  WOUNDS 

of  the  hypochlorite  are  irritating  to  the 
tissues. 

Chemicals  Required  for  the  Prepara- 
tion of  the  Solution. — Three  chemicals 
are  indispensable  :  calcium  chlorid,  dry  so- 
dium carbonate,*  and  sodium  bicarbon- 
ate. As  obtained  commercially,  the  compo- 
sition of  the  last  two  of  these  chemicals  is 
fairly  uniform  and  will  suffice  for  all  prac- 
tical requirements.  In  commercial  calcium 
chlorid,  however,  the  active  chlorine  (free 
chlorine)  varies  within  wide  limits.  Be- 
fore the  calcium  chlorid  is  used,  it  is  nec- 
essary to  determine  its  percentage  of  free 
chlorine  by  titration. 

Titration  of  the  Calcium  Chlorid. — For 
this  purpose  the  following  apparatus  is 
necessary  : 

A  25  ex.  English  burette  graduated  in 

*  This  salt  is  obtained  without  any  difficulty 
in  the  open  market  under  the  name  of  "Solvay's 
soda"  or  "carbonate  of  soda,  Solvay."  Where 
only  the  crystalline  carbonate  can  be  obtained, 
2.85  times  more  of  it  than  of  the  dry  salt  must  be 
used  (on  account  of  the  water  of  crystallization). 


DAKIN'S  SOLUTION  57 

tenths  of  a  cubic  centimeter;  a  10  c.c. 
pipette,  and  a  deci-normal  solution  of  so- 
dium hyposulphite. 

The  standard  deci-normal  solution  of 
sodium  hyposulphite  is  on  the  market,  or 
it  can  be  prepared  by  dissolving  25  grams 
of  crystalline  chemically  pure  sodium  hy- 
posulphite in  one  liter  of  distilled  water. 
The  solution  is  correct  if  it  decolorizes  an 
equal  volume  of  a  deci-normal  iodine  solu- 
tion made  by  dissolving  1.27  grams  of 
iodine  and  5.0  grams  of  potassium  iodid  in 
100  ex.  of  water. 

Everything  being  ready  for  the  quanti- 
tative test,  select  an  average  sample  of  the 
calcium  chlorid  by  selecting  small  quanti- 
ties at  random  from  different  parts  of  the 
stock  and  carefully  mixing  them. 

Weigh  off  20  grams  of  this  average 
sample  and  dissolve  it  as  completely  as 
possible  in  1  liter  of  tap  water;  let  the  so- 
lution stand  for  several  hours,  shaking  it 
from  time  to  time.  Filter. 

With  the  graduated  pipette,  measure  off 
10  c.c.  of  the  clear  fluid,  and  add  to  them 


58  IRRIGATION  OF  WOUNDS 

20  ce.  of  the  deci-normal  solution  of  po- 
tassium iodid  and  2  c.c.  of  acetic  or  hydro- 
chloric acid.  To  this  mixture,  drop  by 
drop,  a  deci-normal  solution  of  sodium  hy- 
posulphite should  be  added  until  the  fluid 
is  entirely  decolorized. 

The  number  of  cubic  centimeters  of  the 
solution  of  sodium  hyposulphite  which  are 
required  to  decolorize  the  solution  multi- 
plied by  1.775  will  give  the  weight  of  the 
active  chlorine  contained  in  100  grams  of 
calcium  chlorid. 

Having  found  this  number,  by  referring 
to  the  following  table  the  amount  of  cal- 
cium chlorid,  carbonate  of  soda  and  so- 
dium bicarbonate  which  is  necessary  to 
prepare  10  liters  of  Dakin's  Solution  can 
be  read  off. 

Example. — If  16.6  c.c.  of  the  deci-nor- 
mal hyposulphite  solution  were  necessary 
to  decolorize  the  test  solution,  the  titer  of 
active  chlorine  of  the  sample  of  calcium 
chlorid  is  the  following: 

16.6  X  1.775  =  29.7  per  100 


DAKIN'S  SOLUTION  59 

The  quantities  necessary  to  make  10 
liters  of  the  solution  would  be  in  this  case  : 

Calcium  chlorid 154  grams 

Carbonate    of    soda,     anhy- 
drous        77 

Bicarbonate  of  soda 64 


Quantities   Used 

rr-r=! 

to  Prepare  10  Liters  or  Darin's 

Liter  oe 

Solution;  ClONa  Content  0.45 

ro  0.50  per  cent. 

Calcium 

Chlorid 

Chlorid  of 

Carbonate  of 

Bicarbonate  of 

Calcium 

Soda,  Dry 

Soda 

20 

230  gms. 

US  gms. 

96  gms. 

21 

220 

no 

92 

22 

2IO 

105 

88 

23 

20O 

IOO 

84 

24 

IQ2 

96 

80 

25 

184 

92 

76 

26 

177 

89 

72 

27 

17c 

85 

70 

28 

164 

82 

68 

29 

159 

80 

66 

30 

154 

77 

64 

31 

148 

74 

62 

32 

144 

72 

60 

33 

140 

70 

59 

34 

135 

68 

57 

35 

132 

66 

55 

36 

128 

64 

53 

37 

124 

62 

52 

■  a 

If  we  have  only  the  crystalline  sodium 
carbonate,   it  will  be  necessary   to   use 


6o         IRRIGATION  OF  WOUNDS 

219.45  grams  of  the  crystalline  carbonate 
instead  of  77  grams  of  the  anhydrous 
salt. 

The  Preparation  of  D akin3 s  Solution. — 
To  prepare  10  liters  of  the  solution: 

1.  Weigh  out  accurately  the  quantities 
of  calcium  chlorid,  sodium  carbonate  and 
sodium  bicarbonate  required; 

2.  Place  the  calcium  chlorid  in  a  12  liter 
flask,  add  5  liters  of  tap  water,  shake  vig- 
orously for  several  minutes,  and  then  let 
it  stand  for  6  to  12  hours  (over  night,  for 
example)  ; 

3.  At  the  same  time,  dissolve  the  car- 
bonate and  bicarbonate  of  soda  in  the 
other  five  liters  of  cold  water  ; 

4.  Pour  the  solution  of  soda  salts  into  the 
flask  containing  the  supersaturated  solu- 
tion of  calcium  chlorid;  shake  thoroughly 
for  several  minutes  and  allow  the  mixture 
to  stand  in  order  to  permit  the  carbonate  of 
calcium,  which  is  formed,  to  settle  down. 
At  the  end  of  half  an  hour,  syphon  off  the 
supernatant  liquid  and  filter  it  through 
two  thicknesses  of  filter  paper.  One  should 


DAKIN'S  SOLUTION  61 

obtain  a  perfectly  clear  liquid  whicn  must 
be  protected  from  the  light. 

Exposure  to  light  changes  the  hypo- 
chlorite solution  fairly  quickly.  If  the  pre- 
pared solution  has  to  be  kept  for  any 
length  of  time  it  is  advisable  to  preserve 
it  in  large  bottles  or  carboys  of  black  glass. 

This  solution  should  never  be  exposed 
to  a  temperature  above  400  C.  (1040  F.), 
and  it  goes  without  saying  that  it  should 
never  be  sterilized  in  the  autoclave.  Heat 
changes  the  hypochlorite  into  a  compound 
which  contains  chlorids  and  chlorates,  and 
deprives  it  of  all  antiseptic  properties. 

Titration  of  D akin3 s  Solution. — It  is  ad- 
visable to  control  the  titer  of  the  solution 
from  time  to  time.  For  this  purpose,  the 
same  apparatus  and  reagents  are  neces- 
sary as  are  required  for  the  estimation  of 
the  active  chlorine  in  the  calcium  chlorid: 

To  10  c.c.  of  the  solution  add  20  c.c. 
of  the  deci-normal  solution  of  potassium 
iodid  and  2  c.c.  of  acetic  or  hydrochloric 
acid.  Titrate  this  mixture  with  a  deci-nor- 


62  IRRIGATION  OF  WOUNDS 

mal  solution  of  sodium  hyposulphite  until 
it  is  completely  decolorized. 

The  number  of  cubic  centimeters  used 
multiplied  by  0.03725  will  give  the  weight 
of  the  sodium  hypochlorite  in  100  ex.  of 
the  solution. 

The  solution  is  correct  if  12  to  13  c.c. 
of  the  deci-normal  hyposulphite  solution 
are  required  to  decolorize  the  quantity  of 
test  solution  indicated  above: 

13  X  0.03725  =  0.485  ClONa  per  100. 

Estimation  of  the  Alkalinity  of  D akin' s 
Solution. — It  is  a  simple  matter  to  distin- 
guish the  solution  made  in  the  way  here 
described  from  commercial  hypochlorite 
solutions  and  Labarraque  Solution: 

For  this  purpose  place  about  20  c.c.  of 
the  solution  to  be  tested  in  a  beaker  and 
sprinkle  a  few  centigrams  of  powdered 
phenolphthalein  on  the  surface.  With 
properly  prepared  Dakin's  Solution  abso- 
lutely no  coloration  will  ensue  whereas 
Javel  water  and  Labarraque  Solution  will 
give  an  intense  red  color,  indicating  in  the 
latter  the  presence  of  free  caustic  soda. 


APPENDIX  II 

THE     MICROSCOPICAL     EXAMINATION      OF 

WAR    WOUNDS     BY    THE     CARREL 

METHOD    (DR.    VINCENT) 

Its  Aim. — The  microscopical  examina- 
tion of  the  wounds  is  necessary: 

i.  To  gain  knowledge  of  the  degree  of 
infection  of  the  wounds  at  the  beginning 
of  and  during  the  course  of  the  treat- 
ment; 

2.  To  follow  the  progress  of  the  disin- 
fection so  that,  if  the  wound  does  not  im- 
prove as  it  should,  additional  measures 
can  be  instituted; 

3.  To  substantiate  the  clinical  symptoms 
and  in  order  to  determine  the  proper  time 
for  the  surgical  closure  of  the  wound, 
without  danger  of  recurring  infection. 

Apparatus  Required.  —  1.  A  fairly 
strong  platinum  loop  mounted  on  a  glass 

63 


64  IRRIGATION  OF  WOUNDS 

or  metal  rod;  or  a  swab   (iron  wire,  a 
small  cotton  pledget  fastened  at  one  end)  ; 

2.  An  alcohol  lamp  or  Bunsen  burner; 

3.  Glass  slides  for  the  specimens,  with 
labels  previously  pasted  on  each  side; 

4.  A  slide  box  for  the  specimens. 

Obtaining  the  Specimens. — The  irriga- 
tion should  be  suspended  for  at  least  two 
hours  before  the  specimen  is  taken,  so  that 
the  secretions  shall  not  be  too  much  di- 
luted. 

While  the  dressings  are  being  removed, 
the  platinum  loop  should  be  heated  in  the 
flame  to  a  bright  red,  or  a  sterile  swab 
should  be  picked  up. 

The  part  of  the  wound  is  sought  for 
which  seems  to  be  most  infected  (site  of 
necrosis,  grayish  parts  of  the  wound, 
small  tracts  not  easily  reached  by  the  an- 
tiseptic, sequestra  of  bone,  etc.,  etc.)  and 
the  platinum  loop  or  the  swab  is  rubbed 
over  its  surface  so  as  to  remove  the  secre- 
tions which  cover  it. 

The  Smears. — Holding  the  glass  slide, 
with  the  label  facing  up,  in  the  left  hand, 


MICROSCOPICAL  EXAMINATION    65 

and  the  platinum  loop  or  cotton  swab  in 
the  right  hand,  the  wound  secretions  are 
spread  on  the  glass  slide  in  as  thin  a  layer 
as  possible.  This  is  accomplished  by  rub- 
bing the  loop  or  swab  on  the  slide  with  a 
slight  rotary  movement. 

The  platinum  loop  is  heated  to  a  red  heat 
in  the  flame  before  laying  it  down  and  the 
swab  is  dropped  into  a  receptacle  filled 
with  an  antiseptic.  The  name  of  the 
wounded  person,  the  number  of  his  bed, 
and  the  identification  mark  of  the  wound 
are  written  on  the  label. 

The  slides  are  dried  in  the  air  or  lightly 
passed  over  the  flame,  and  are  kept,  until 
examined,  in  a  specimen  box. 

Staining  the  Slides. — This  is  done  in 
the  laboratory  and  the  following  appara- 
tus is  necessary  : 

1.  Alcohol  lamp  or  Bunsen  burner; 

2.  Staining  solutions  in  dropper  bottles. 
We  use  preferably  carbol-thionine  ;  if 

this  cannot  be  obtained,  a  10  per  cent, 
solution  of  carbol-fuchsin,  methylene  blue 
or  gentian  violet. 


66  IRRIGATION  OF  WOUNDS 

Formula  for  carbol-thionine  solution: 

Thionine   I  gram 

Carbolic  acid  (crystalline) ...      I  gram 

Alcohol  95  per  cent 10  grams 

Water ioo      " 

The  thionine  and  the  alcohol  are  tritu- 
rated in  a  small  mortar,  the  carbolic  acid 
is  then  added,  and  the  mixture  thoroughly- 
stirred  up.  Two-thirds  of  the  water  is 
added  little  by  little,  the  mixture  poured 
into  a  bottle  with  ground  glass  stopper. 
The  mortar  is  then  washed  off  with  the 
remaining  one-third  of  the  water,  which 
is  also  emptied  into  the  bottle.  After  24 
hours  the  solution  is  ready  for  use. 

A  simple  solution  can  be  made  by  mix- 
ing 10  c.c.  of  a  saturated  solution  of 
thionine  in  90  per  cent,  alcohol  with  100 
c.c.  of  1  per  cent,  solution  of  carbolic  acid 
in  water. 

3.  Various  reagents:  absolute  alcohol, 
alcohol-ether,  etc.  (are  not  indispensable)  ; 

4.  Wash-bottle  or  running  water; 


PLATE  X 


A 


B 

PlNCHCOCK    AND    SAFETY-PIN 

A. — Enlarged  view  of  pinchcock  used  to  regulate  the 
flow  of  the  antiseptic  solution. 

B. — Enlarged  view  of  safety-pin  showing  method  of 
holding  tubes  and  glass  distributors  in  place. 


MICROSCOPICAL  EXAMINATION    67 

5.  Glass  bowl  or  some  receptacle  to  re- 
ceive the  waste  water; 

6.  Small  squares  of  filter  paper. 

Preparation  of  the  Specimens. 

1.  Drying. — The  slides  are  dried  imme- 
diately after  preparing  them  or,  what  is 
just  as  good,  are  left  to  dry  in  the  box. 

2.  Fixing. — The  smears  must  be  fixed 
on  the  slides  so  that  they  do  not  wash  off 
during  the  staining.  For  this  purpose  fix- 
ation by  heat  is  the  rule.  The  slide 
is  held  at  one  end,  specimen  surface  up, 
and  is  passed  fairly  rapidly  through  the 
flame  three  times,  as  in  "cutting  bread." 
The  slides  can  also  be  fixed  in  a  mixture 
of  equal  parts  of  absolute  alcohol  and 
ether,  by  pouring  several  drops  on  the 
smear,  and  allowing  it  to  evaporate. 

3.  Staining. 

(a)  Pour  enough  of  the  staining  fluid 
(carbol-thionine)  on  the  smear  to  cover  it 
completely. 

(b)  Let  the  stain  act  for  a  half  to  one 
minute. 


68         IRRIGATION  OF  WOUNDS 

(c)  Drain  off  the  stain. 

(d)  Wash  rapidly  with  water  either 
with  the  wash-bottle  or  under  the  tap. 

(e)  Dry  in  the  air.  The  drying  may  be 
hastened  by  gently  heating  the  slide,  or  by 
blotting  up  the  excess  of  water  with  a 
small  piece  of  filter  paper. 

Examination. — Place  a  drop  of  cedar 
oil  on  the  slide. 

Place  the  slide  on  the  stage  of  the  mi- 
croscope and  fasten  the  side  with  the 
clips. 

With  the  coarse  adjustment,  lower  the 
oil  immersion  lens  until  it  comes  into  con- 
tact with  the  cedar  oil,  about  2  mm.  from 
the  slide.  Proceed  very  carefully. 

Place  the  eye  at  the  eyepiece,  secure 
sufficient  illumination  by  adjusting  the 
mirror  of  the  microscope. 

Slowly  lower  the  objective  until  the  ob- 
ject is  seen  more  or  less  clearly.  Then 
focus  carefully  with  the  fine  adjustment 
until  the  image  stands  out  sharply. 

Make  the  examination. 


MICROSCOPICAL  EXAMINATION    69 

Raise  the  objective  (coarse  adjust- 
ment) ;  remove  the  specimen. 

Clean  the  objective  by  wiping  it  with  a 
piece  of  fine  linen. 

Preservation  of  the  Specimens. — Re- 
move the  drop  of  cedar  oil  from  the  slide 
by  dissolving  it  with  a  few  drops  of  xylol. 
Allow  it  to  dry. 

Put  the  slides  away  in  the  slide  boxes. 

Cleaning  the  Slides. — The  slides  which 
are  not  kept  are  thrown  into  a  receptacle 
containing  denatured  alcohol.  They  can 
be  used  again  after  they  have  been 
cleaned. 

For  that  purpose  they  are  removed 
from  the  denatured  alcohol,  drained,  and 
placed  in  a  pan  containing  a  4  per  cent, 
solution  of  sodium  carbonate  (crystals), 
and  are  boiled  for  half  an  hour.  After 
having  cooled  off,  they  are  washed  in 
water. 

Then  they  are  boiled  again  for  half  an 
hour  in  a  5  per  cent,  solution  of  hydro- 
chloric acid,  or  in  the  following  solution: 


70         IRRIGATION  OF  WOUNDS 

Water  iooo 

Potassium  bichromate 50 

Sulphuric  acid 100 

Rinse  in  water,  wipe,  dry,  preserve  dry 
protected  from  dust,  or  in  alcohol. 

The  Examination  of  the  Slides. — This 
should  be  done  in  a  laboratory  by  trained 
bacteriological  workers. 

Fundamental  Principles. — If  a  slide 
stained  with  carbol-thionine  is  examined 
under  the  microscope,  we  see  the  follow- 
ing: 

1.  Cells  with  the  nuclei  stained  violet; 
there  are  leucocytes  which  have  only  a  sin- 
gle nucleus  (mononuclear  leucocytes)  ;  or 
a  nucleus  divided  into  several  lobes  (poly- 
nuclear  leucocytes). 

2.  Cellular  detritus  stained  violet. 

3.  Occasionally  large  flat  cells  with  a 
small  violet  nucleus  (cells  from  the  skin). 

4.  Round  bodies  stained  green  (red 
blood  cells). 

5.  Bacteria  stained  a  deep  violet.  They 
occur  in  two  varieties  : 


MICROSCOPICAL  EXAMINATION    71 

(a)  As  more  or  less  well  marked  round 
spots:  cocci; 

If  they  occur  in  pairs:  diplococci. 

In  groups  of  four:  tetracocci. 

If  they  are  grouped  in  chains,  the  one 
following  the  other:  chain  cocci  (they  are 
generally  referred  to  as  streptococci,  and 
are  the  cause  of  various  kinds  of  suppura- 
tions and  inflammations). 

If  they  appear  in  clusters  :  cluster  cocci 
(generally  spoken  of  as  staphylococci; 
very  common  in  most  infections). 

(b)  Little  rods  of  varying  lengths  and 
sizes,  bacilli. 

These  occur  singly;  in  groups  of  two, 
diplobacilli,  or,  when  they  occur  in  chains, 
streptobacilli. 

Counting  the  Organisms. — In  the 
smear  method,  the  number  of  bacteria  is 
of  greater  importance  than  the  particular 
variety,  as  they  cannot  be  positively  iden- 
tified by  their  morphological  characteris- 
tics. Nevertheless,  the  bacillus  variety 
nearly  always  indicates  a  serious  infec- 
tion. To  calculate  the  number  of  bacteria 


72         IRRIGATION  OF  WOUNDS 

it  is  necessary  to  count  the  number  in  a 
field  of  known  size.  It  is  customary  to 
take  as  the  unit  the  microscopic  field,  that 
is  to  say,  the  round  area  which  one  sees 
in  looking  through  the  microscope  (mi- 
croscope with  a  No.  3  eyepiece  and  1/12 
oil  immersion  objective). 

The  estimation  of  the  number  of  bac- 
teria found  in  a  series  of  fields  is  approxi- 
mate and  can  be  quickly  made  when  there 
are  many  to  each  field.    We  class  them  as  : 

1.  Innumerable; 

2.  50  to  100  to  the  field; 
3-  3°  to  50  to  the  field 

4.  20  to  30  to  the  field 

5.  15  to  20  to  the  field 

6.  10  to  15  to  the  field. 

When  there  are  fewer  than  10  to  15  to 
the  field,  it  is  possible  to  count  them  ex- 
actly. The  bacteria  should  be  counted  in 
ten  successive  fields,  starting  from  one 
point,  then  in  ten  other  fields  starting  at  a 
point  at  some  distance  from  the  first,  then 
in  a  third  series  of  ten  fields,  and  the  av- 


MICROSCOPICAL  EXAMINATION    73 

erage  taken.  The  results,  although  purely- 
relative,  will  be  found  to  correspond 
roughly,  especially  when  all  the  estima- 
tions are  made  by  the  same  observer. 

Clinical  Indications  Deduced  from  the 
Microscopical  Examination. — (a).  The 
disinfection  should  reduce  the  number  of 
bacteria.  If  the  latter  remains  stationary 
for  several  days  or  increases,  the  surgeon 
should  examine  the  wound  and  ascertain 
the  reason  for  the  slowing  of  the  disinfec- 
tion. Insufficient  irrigation  demands  an 
increase  in  the  number  of  tubes,  a  change 
in  their  position  or  removal  and  reinser- 
tion. The  lack  of  results  may  be  due  to 
bacterial  foci  from  necrotic  tissue,  foreign 
bodies,  projectiles,  pieces  of  clothing, 
bone  sequestra,  etc.,  non-irrigated  por- 
tions of  the  wound,  poorly  applied  dress- 
ings, mistakes  in  technic,  etc. 

(b)  When  the  number  of  bacteria  is  re- 
duced to  about  one  to  each  field,  the  ex- 
aminations must  be  made  with  especial 
care  on  numerous  smears  which  should 


74  IRRIGATION  OF  WOUNDS 

be  taken  from  different  parts  of  the 
wound. 

When  only  isolated  cocci  or  diplococci 
are  seen,  and  only  one  is  found  in  every 
four  or  five  fields,  and  if  this  result  has 
been  verified  by  two  or  three  successive 
examinations  at  an  interval  of  one  or  two 
days,  the  disinfection  is  practically  ac- 
complished. The  surgeon  may  then  close 
the  wound  with  a  fair  presumption  of  suc- 
cess, no  matter  whether  it  is  a  wound  of 
the  soft  parts  or  a  compound  fracture.* 

Number  of  Examinations. — At  Carrel's 
hospital  the  examinations  are  made  regu- 
larly every  other  day  for  all  the  wounded. 
In  the  other  hospitals,  they  are  made  only 
every  third  or  fourth  day  during  the 
period    of    disinfection,    then   more    fre- 

*  The  time  varies  somewhat,  depending  on  the 
nature  of  the  case  and  the  severity  of  the  preced- 
ing infection.  Compound  infected  fracture  of 
thigh,  6  days  interval  of  sterile  wound;  large 
wound  of  soft  parts,  3  days;  superficial  wound 
of  soft  parts,  2  days. 


PLATE  XI 


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Graphic  Record  of  Bacterial  Count. 


■ 

-•  • 


MICROSCOPICAL  EXAMINATION     J7 

vjuently  as  the  time  approaches  for  the 
surgical  closure  of  the  wound. 

Bacterial  Curve. — The  results  are  re- 
corded for  the  use  of  the  surgeon  and  en- 
tered on  charts  as  a  graphic  bacterial 
curve.  These  curves  are  similar  to  the 
temperature  charts  and  show  at  a  glance 
the  course  of  the  infection  and  the  prog- 
ress of  the  disinfection  {See  Plate  XI). 


GLOSSARY 


ENGLISH    TO   FRENCH 


Adhesive  plaster.  Sparadrop  adhesive 

Bacteriological  curve,  courbe  microbienne 

Bicarbonate  of  soda,  bicarbonate  de  soude 

Carbonate  of  soda,  carbo\ftate  de  soude 

Chlorid  of  lime,  Chlorure  de  chaux 

Compresses,  compresses 

Conducting  connectors,  glass,  raccords  adduc- 
teurs 

Conducting  tube,  tube  adducteur 

Cotton  pads,  coussins  de  coton 

Distributing  tubes,  small  straight  glass,  petits 
raccords  droits 

Distributing  tubes,  tubes  distributeurs 

Distributors,  glass,  raccords  distributeurs 

Dressings,  pasements 

Flask,  ampoule 

Gloves,  rubber,  gantes  de  caoutchouc 

Hyposulphite  of  soda,  hyposulphite  de  soude 

Instillation  tubes,  tubes  distributeurs 

Microscopic  slides,  Frottis 

Necrotic  tissue,  les  tissus  sphacilas 

Nurse,  Vinûrmère 

Pinchcock,  pince  de  Mohr  à  rassorts 

Rubber  gloves,  gantes  de  caoutchouc 

Safety-pins,  épingles  de  sûreté 

79 


80  GLOSSARY 

Slides,  microscopic,  frottis 

Sloughs,  les  tissus  sphacilas 

Smears,  lames 

Straight   glass   distributing   tubes,   small,   petits 

raccords  droits 
Titration,  titrage 
Wounded  man,  le  blessé 
Wounds,  les  plaies 


FRENCH   TO   ENGLISH 

Ampoule,  flask  for  fluid 
Bicarbonate  de  soude,  bicarbonate  of  soda 
Blessé,  le,  wounded  man,  the 
Chlorure  de  chaux,  chloride  of  lime 
Courbe  microbienne,  bacteriological  curve 
Carbonate  de  soude,  carbonate  of  soda 
Compresses,  squares  of  gauze,  single  thickness 
Coussins  de  coton,  pads  of  gauze  with  cotton  be- 
tween 
Epingles  de  sûreté,  safety-pins 
Frottis,  microscopic  slides 
Gantes  de  coautchouc,  rubber  gloves 
Hyposulphite  de  soude,  hyposulphite  of  soda 
Infirmière,  V,  the  nurse 
Lames,  smears 
Pasements,  dressings 
Pince  de  Mohr  à  rassort,  pinchcock 
Plaies,  les,  wounds,  the 

Raccords  adducteurs,  glass  conducting  connectors 
Raccords  distributeurs,  glass  distributors 
Raccords  droits  petits,  small  straight  glass  dis- 
tributing tubes 
Sparadrop  adhesive,  adhesive  plaster 


GLOSSARY 


81 


Tissus  sphacilas,  necrotic  tissue  or  sloughs 
Titrage,  titration 
Tube  adducteur,  conducting  tube 
Tubes   distributeurs,   distributing   or  instillation 
tubes,  to  be  placed  in  wound 


Metric  Equivalents  in  Inches 


Meters 


Inches 


Millimeter ooi  .03937 

Centimeter 01  «3937 

Meter 1. 39.3685 


Metric  Equivalents  in  Troy  Weights 


Grains 

Grams 

Grains 

Grams 

O.I543 

.01 

154  323 

10 

0.7717 

05 

231 

485 

15 

1-543 

1 

308 

647 

20 

7.716 

5 

385 

809 

25 

15-432 

I 

771 

617 

50 

30.865 

2 

925 

941 

60 

46.297 

3 

1080 

264 

70 

61.729 

4 

1543 

235 

100 

77.162 

5 

3086 

47 

200 

INDEX 


Absorbent     cotton      for         tion  of,  47,  48;  in  pre- 


pads,  use  of,  23. 

Acetic  acid  in  testing,  use 
of,  58. 

Adhesive  plaster,  for 
holding  dressing,  25  ; 
for  holding  tubes,  28. 

Alcohol  as  re-agent,  ab- 
solute, 66;  for  preserva- 
tion of  specimens,  de- 
natured, 69;  for  fixing 
slides,  absolute,  67;  for 
making  thionine,  66. 

Alcohol-ether  as  re- 
agent, 66. 

Alcohol  lamp  for  stain- 
ing, use  of,  65;  in  mi- 
croscopical examination, 
use  of,  64. 

Alkali,  injurious  action 
of  caustic,  55. 

Alkalinity,  estimation 
of,  62. 

Anhydrous  sodium  car- 
bonate vs.  crystalline 
salt,  60. 

Antiseptic,  action  on 
skin,  24;  continuous  ac- 


paring  slides,  use  of,  65. 

Antiseptic  solution,  pro- 
tection of  skin  from,  29. 

Apparatus,  irrigating,  30; 
sterilization  of,  17. 

Autoclave,  sterilization 
by,  23. 

Bacilli,    71  ;    diplobacilli, 

71  ;    streptobacilli,   71. 
Bacteria,    70;    cocci,    71; 

diplococci,  71  ;  tetracocci, 

71  ;      streptococci,      71  ; 

staphylococci,   71. 
Bacterial  curve,  77. 
Bacterial  foci  in  necrotic 

tissue,  73. 
Bacteriological  count,  71. 
Bandage,  use  of,  29. 
Basins,  use  of  sterile,  26. 
Bed  pad,  protection  of,  51. 
Bicarbonate      of      soda, 

quantity  of,  59. 
Binder,     adjustment     of, 

29;  flannel,  use  of,  25. 
Boiling,       cleansing      of 

slides  by,  69. 


$3 


84 


INDEX 


Bottles,   use  of   dropper, 

65. 

Box  for  slides  of  speci- 
mens, 64,  65. 

Boxes  for  sterilizing, 
metal,  24. 

Bunsen  burner  in  micro- 
scopical  examination, 
use  of,  64;  for  staining, 
use  of,  65. 

Burette  used  for  titra- 
tion, 56. 

Calcium  carbonate,  cry- 
stalline vs.  anhydrous, 
60. 

Calcium  chlorid,  com- 
mercial, 56;  in  antisep- 
tic solution,  use  of,  56; 
quantity  of,  59;  sam- 
pling of,  57- 

Calculation  of  bacterio- 
logical count,  72,  7Z. 

Carbol-fuchsin  solution 
for  staining,  65. 

Carbo-thionine  for  stain- 
ing slides,  65,  67;  form- 
ula for,  66. 

Carbo-thionine  solution, 
preparation  of,  66. 

Carbolic  acid  in  carbo- 
thionine,  use  of,  66;  in 
making  thionine,  use  of, 
66. 

Carbonate   of   soda,    for 


cleansing  slides,  69; 
quantity  of,  59. 

Caustic  alkali,  injurious 
action  of,  55. 

Caustic  soda,  indication 
of  presence  of,  62 

Cells  with  violet  nucleus, 
flat,  70. 

Cedar  oil  from  slides,  re- 
moval of,  69. 

Chlorine,  active,  56;  con- 
tent in  calcium  chlorid, 
58. 

Clamp,  38. 

Cleansing  of  apparatus, 
41  ;  of  stained  slides,  68. 

Cleansing  solution, 
formula  for,  70. 

Clinical  indications,  73- 

Closing  of  wound,  74; 
time  of,  25. 

Cocci,  microscopic  find- 
ings of,  71  ;  isolated,  74. 

Compresses  of  gauze,  de- 
scription of,  23;  use  of, 
28;  use  of  vaselined, 
28;  sterile  vaseline,  24; 
preparation  of  vase- 
line, 24;  see  also  tam- 
pons. 

Conducting  connector, 
Y-shaped  glass,  42. 

Conducting  tubes,  de- 
scription of  primary, 
30;  use  of  primary,  30; 


INDEX 


«S 


secondary,  30;  use  of 
secondary,  30  ;  connec- 
tion with  rubber,  42. 

Connectors,  glass  con- 
ducting, 37. 

Connecting  tube,  attach- 
ing, 42. 

Cotton  for  pads,  use  of 
absorbent,  23;  for  pads, 
use  of  non-absorbent, 
23  ;  to  plug  flask,  sterile, 
42. 

Cotton  pads,  23;  com- 
presses held  by,  29;  de- 
scription of,  23  ;  size  of, 

23- 

Cotton  pledget  in  micro- 
scopical examination, 
use  of,  64. 

Counting  the  Organisms, 

7h  72,  73- 

Crystalline  sodium  car- 
bonate vs.  anhydrous 
salt,  60. 

Curve,  bacterial,  77. 

Dakin's  solution,  26;  for 
cleansing  apparatus,  41  ; 
irrigation  treatment 
with,  15;  mixing  of,  60; 
moistening  of  com- 
presses with,  28;  prep- 
aration of,  55,  60;  ti- 
tration of,  61. 

Daufresne's  technic  for 


preparation  of  solution, 

55- 
Decolorization  test,  57. 
Denatured    alcohol,    use 

of,  67. 
Detritus  visible  on  plates, 

cell,  70. 
Diplococci,    isolated,    74  ; 

microscopic  findings  of, 

71. 
Disinfection,  measure  of, 

73- 
Distilled  water,  use  of, 

57- 

Distributing  tubes,  15  ; 
connection  of  rubber, 
42;  description  of,  15, 
16;  perforated,  16;  rôle 
of,  16;  simple,  15;  sizes 
of,  16;  varieties  of,  15; 
with  connecting  tubes, 
connection  of,  37;  small 
glass,  41. 

Distributors,  description 
of  glass,  38. 

Dressing,  antiseptic  solu- 
tion to  soak,  48;  ma- 
terials for,  26. 

Dressing  wound,  nurse's 
part  in,  26,  27. 

Dropper   bottles,    use   of, 

65. 
Drying   of    slides   in   air, 
68;  of  specimens,  67;  of 
stained  slides,  68. 


86 


INDEX 


Elevation  of  flask,  42. 
Examination    of     slides, 

70. 
Examinations,       number 

of,  74. 

Flannel  binder,  adjust- 
ment of  many-tailed, 
29;  use  of,  25. 

Flask,  description  of,  30; 
setting  up  of,  42. 

Filter  paper,  use  of,  67. 

Fixation  by  heat,  67. 

Foci  from  necrotic  tissue, 
bacterial,  73. 

Focusing  of  microscope, 
68. 

Forceps,  Kocher's  sterile, 
26. 

Fracture  of  thigh,  time 
interval  for  examining, 
74- 

Gauze,  use  of  unstarched, 

25. 

Gauze  compresses,  de- 
scription of,  27;  vase- 
line,  24. 

Gentian  violet  for  stain- 
ing, 65. 

Gloves,  use  of  rubber, 
26. 

Glass  conducting  con- 
nectors, 37. 

Glass    distributors,    con- 


nection of,  47;  descrip- 
tion of,  38. 

Glass  distributing  tubes, 
small,  41. 

Glass  slides  in  micro- 
scopical examination, 
use  of,  64. 

Heat,  fixation  by  67. 

Hydrochloric  acid  for 
testing,  58;  for  cleaning 
slides,  69. 

Hypochlorite  of  soda 
content,  62;  in  Dakin's 
Solution,  use  of,  55. 

Hypochlorite  of  sodium, 
irrigation  treatment 
with,  15;  see  also  Da- 
kin's  Solution. 

Hypochlorite  solution, 
exposure  of,  61; 
strength  of,  55  ;  temper- 
ature of,  61. 

Hyposulphite  of  soda, 
57;  as  re-agent,  61;  de- 
colorization  by,  58. 

Indications,  clinical,  73. 
Injection    by    syringe    to 

test  tubes,  41. 
Infection,  examination  to 

determine  degree  of,  25. 
"Instillation"  tubes,  see 

Distributing  Tubes. 
Iodine  solution,  57. 


INDEX 


87 


IODID    OF    POTASSIUM,    57- 

Irrigation,  care  to  secure 
free,  48;  technic  of,  47. 

Irritation  due  to  strong 
solution,  56. 

Javel  water,  coloration 
of,  62;  injurious  action 
of,  55- 

Kocher's  forceps,  26;  in- 
jurious action  of,  55. 

Labarraque  solution, 
coloration  of,  62. 

Lamp  in  microscopic  ex- 
amination, use  of,  64. 

Leucocytes,  mononuclear, 
70;  polynuclear,  70;  vi- 
sible on  microscopic 
plates,  70. 

Linen  as  covering,  use 
of,  24;  for  cleaning  the 
objective,    use    of    fine, 

69. 
Linen     thread     used     to 
close   distributing  tubes, 
16. 

Metal  boxes  for  steriliz- 
ing, 24. 

Methylene  blue  for 
staining,  65. 

Microscope,  adjustment 
of,  68. 


Microscopic  field  as 
counting  unit,  72. 

Microscopic  findings, 

70. 

Microscopical  examina- 
tion, purpose  of,  63. 

Mirror  of  microscope,  ad- 
justment of,  68. 

Mononuclear  leucocytes, 
70. 

Mounting  material  from 
smears,  65. 

Necrosis,  smears  taken 
from  site  of,  64. 

Necrotic  tissue,  bacterial 
foci  from,  73;  excision 
of,    27;     smears     from, 

65. 

Nonabsorbent  cotton  for 

pads,  use  of,  23. 
Nurse's   part   in   dressing 

wound,  26,  27. 

Obstructions  in  tubes,  re- 
moval of,  48. 

Pad,  compresses  held  by 
cotton,  29;  sterilization 
of  large,  24;  steriliza- 
tion of  small,  23. 

Paper,  white,  use  as  cov- 
ering, 24. 

Perforation  of  walls  of 
tubing,  16. 


88 


INDEX 


Permeability  of  tubes, 
testing  of,  48. 

Phenolphthalein  in  al- 
kalinity test,  62. 

Pince  de  Mohr  à  rassort, 
38. 

PiNCHCocK,  38;  use  of,  37, 
48/     " 

Pipette  in  filtration,  use 
of,  57- 

Plaster,  use  of  adhesive, 

25. 
Platinum  loop  in  micro- 
scopical       examination, 
use  of,  63;  used  for  ob- 
taining smears,  64. 

POLYNUCLEAR  LEUCOCYTES, 
70. 

Potassium  bichromate, 
cleansing  solution  con- 
taining, 70. 

Potassium  iodid,  57;  as 
re-agent,  61. 

Preparation  of  Dakin's 
Solution,  55,  60. 

Preservation  of  speci- 
mens, 69. 

Quantitative  test  of  cal- 
cium chlorid,  57. 

Raccords  adducteurs,  37- 
Raccords  distributeurs,  38. 
Raccords  droits,  petits,  41. 
Re-agents   used   in   titra- 


tion of  Dakin's  Solu- 
tion, 61. 

Rubber  gloves,  use  of, 
26. 

Rubber  tubing,  examina- 
tion of,  48;  use  of,  41. 

Rubber  sheeting  for  cov- 
ering bed  pad,  51. 

Safety-pins  to  hold  ap- 
paratus, 47;  to  hold  cot- 
ton pad,  29;  use  of,  25. 

Scissors,    sterile,  26. 

Secretions,  remarks  on 
examination   of    wound, 

25. 

Sheeting  to  cover  bed 
pad,  rubber,  51. 

Setting  up  irrigation  ap- 
paratus, 42. 

Slides,  cleaning  of,  69; 
drying  of,  65;  examina- 
tion of,  68,  70;  staining 
of,  65,  67,  69. 

Sliding  carrier  on  stand, 
42. 

Smear  method  of  count- 
ing   organisms,    71,    72, 

73- 
Smears,  64;  collection  of 
necrotic  tissue  for,  64; 
fixing  of,  67  ;  placed  up- 
on slides,  necrotic  tis- 
sues from,  65;  prepara- 
tion of,  67. 


INDEX 


89 


Soap-suds  for  cleansing 
apparatus,  35. 

Soda,  indication  of  pres- 
ence of  caustic,  62. 

Soda  Solvay,  56. 

Sodium  bicarbonate, 
quantity  of,  59. 

Sodium  carbonate,  quan- 
tity of,  59;  use  in  anti- 
septic solution,  56. 

Sodium  carbonate  solu- 
tion for  cleansing 
slides,  69. 

Sodium  content,  hypo- 
chlorite of,  62. 

Sodium  hyposulphite,  57; 
decolorization  by,  58. 

Sodium  oleate,  cleansing 
solution  of,  27. 

Solvay  soda,  56. 

Specimens,  method  of  ob- 
taining, 64;  drying  of, 
67;  preparation  of,  67; 
preservation   of,   69. 

Spring  clamp,  42. 

Staining  of  slides,  65, 
67,  69. 

Staining  solutions,  use 
of,  65. 

Staphylococci,  microsco- 
pic findings  of,  71. 

Stand,  attaching  of  flask 
to,  42. 

Sterilization,  of  cotton 
pads,  method  of,  23;  of 


distributing  tubes,  23  ; 
of  tampons,  23. 

Sterilizer,  hot  air,  24. 

Streptococci,  microscopic 
findings  of,  71. 

Sulphuric  acid,  cleansing 
solution  containing, 

70. 

Swab  in  microscopical  ex- 
amination,       use        of, 

64. 
Syringe  to  test  tubes,  in- 
jection by,  51. 

Tampons,   description   of, 
23;  see  also  compresses. 
Tap  water,  use  of,  60. 
Tech  nic     of     irrigation, 

47- 

Temperature  for  steriliza- 
t  i  o  n  of  distributing 
tubes,  23;  for  steriliza- 
tion of  compresses,  23  ; 
for  sterilization  of  vase- 
line compressors,  24;  of 
hydrochlorite  solution, 
61. 

Test  of  calcium  chlorid, 
quantitative,  57. 

Test  tubes  used  for  steril- 
izing, 23. 

Tetracocct,  microscopic 
findings  of,  71. 

Thionine  in  carbo-thion- 
ine,  66;  saturated  solu- 


9o 


INDEX 


tion  of,  66;  simple  solu- 
tion of,  66. 

Threads  used  to  close  dis- 
tributing tubes,  linen, 
16;  as  guy  ropes,  16. 

Tissues,  irritation  of,  56. 

Titration  of  calcium 
chlorid,  56;  of  Dakin's 
Solution,  60;  control  of, 
61. 

Tray  for  dressings,  26. 

Tube  adducteur,  30. 

Tubes  distributeurs,  15. 

Tubes,  insertion  of  28; 
obstruction  in,  48;  per- 
meability of,  48. 

Turkish  toweling,  cover- 
ing of  distributing 
tubes  by,  16;  method  of 
attaching,   16. 

Vaseline,     protection    of 

skin  by,  29. 
Vaseline         compresses, 


preparation       of,       24; 
sterile,  24;  use  of,  28. 

Water,    use   of    distilled, 

57. 

Wound,  closing  of,  74; 
placing  of  tubes  in,  27; 
time  interval  for  exam- 
ining large,  74;  time  in- 
terval for  examining 
superficial,  74;  time  of 
closing,  25;  flushing  of, 
48. 

Wound  secretions,  re- 
marks on  examination 
of,  25. 

Wounds,  use  of  toweling 
in  irrigation  of  flat  sur- 
face, 16;  use  of  towel- 
ing in  irrigation  of  su- 
perficial,   16. 

Xylol,  dissolving  of  cedar 
oil  by,  69. 


Paul  B.  Hoebeb,  67-69  East  59TH  Street,   New  York. 


MEDICAL   MONOGRAPHS 

Published  by 
PAUL  B.   HOEBER 

67^69  East  59th  St.,  New  York 

This  catalogue  comprises  only  our  own  publications.  It  will 
be  noticed  that  particular  care  has  been  exercised  in  the  selec- 
tion of  Monographs  of  timely  interest. 

We  are  always  glad  to  consider  the  publication  of  new  and 
original  medical  works.  Correspondence  with  Authors  is 
invited. 

ADAM:     Asthma  and  Its  Eadical  Treatment.     By  Jamea 
Adam,   m.a.,   m.d.,   f.r.c.p.s.     Hamilton.     Dispensary   Aural 
Surgeon,  Glasgow  Eoyal  Infirmary. 
8vo,  Cloth,  viii+184  Pages,  Illustrated $1.50  net. 

ADLEE:  Primary  Malignant  Growths  of  the  Lungs  and 
Bronchi.  By  I.  Adler,  a.m.,  m.d.,  Prof.  Emeritus  New  York 
Polyclinic,  Consulting  Physician,  German,  Beth-Israel,  Har 
Moriah,  People's  and  Montefiore  Hospitals.  8vo,  Cloth,  xii-f- 
325  Pages,  1  Colored  and  16  Halftone  Plates $2.50  net. 

AMEEICAN    JOURNAL     OF    EOENTGENOLOGY,     THE. 
Official    Organ    of    the    American    Eoentgen    Eay    Society. 
Edited  by  James  T.  Case,  m.d.,  Battle  Creek,  Mich. 
Published  monthly.     (Volume  IV,  No.  1.    Published  January, 
1917) $5.00  per  year. 

ANNALS  OF  MEDICAL  HISTOEY.  Edited  by  Francis  E. 
Packard,  m.d.  Associate  Editors:  Drs.  Harvey  Cushing, 
George  Dock,  Mortimer  Frank,  Fielding  H.  Garrison,  Abra- 
ham Jacobi,  Howard  A.  Kelly,  Arnold  C.  Klebs,  Sir  William 
Osier,  William  Pepper,  Lewis  S.  Pilcher,  David  Eiesman  and 
Edward  C.  Streeter. 

Published  quarterly $6.00  per  year. 

1 


2  HOEBER'S  MEDICAL  MONOGRAPHS 

AEMSTBONG:     I.  K.  Therapy,  with  Special  Reference  to 
Tuberculosis.     By  W.  E.  M.  Armstrong,  m.a.,  m.d.  Dublin. 
Bacteriologist  to  Cent.  Lond.  Ophthalmic  Hosp.,  Late  Asst. 
in  Inoculation  Dept.,  St.  Mary's  Hosp.,  Padding,  W. 
8vo,  Cloth,  x-L.93  Pages,  Illustrated $1.50  net. 

BACH:     Ultra- Violet  Light  by  Means  of  the  Alpine  Sun 
Lamp.    By  Hugo  Bach,  m.d.,  Bad  Elster,  Germany.    Author- 
ized Transi,  from  German. 
12mo,  Cloth,  114  Pages,  Illustrated $1.00  net. 

BABBINGEB,  JANEWAY  AND  FAILLA:  Radium  Therapy 
in  Cancer  at  the  Memorial  Hospital.  (See  Janeway,  Bar- 
ringer  and  Failla.) 

BIGG:  Indigestion,  Constipation  and  Liver  Disorder.  By 
G.  Sherman  Bigg,  Fellow  of  the  Eoyal  College  of  Surgeons; 
Fellow  of  the  Eoyal  Institute  of  Public  Health  ;  Late  Surgeon 
Captain,  Army  Medical  Staff;  Surgeon  Allahabad,  India. 
12mo,  Cloth,  viii+168  Pages $1.50  net. 

BBAUN  AND  FEIESNEE:  Cerebellar  Abscess:  Its  Eti- 
ology, Pathology,  Diagnosis  &  Treatment.  (See  Friesner  & 
Braun.) 

BEOCKBANK:  The  Diagnosis  and  Treatment  of  Heart 
Disease.  Practical  Points  for  Students  and  Practitioners. 
By  E.  M.  Brockbank,  m.d.  (Vict.),  f.r.c.p.,  Hon.  Phys.  Eoyal 
Infirmary,  Manchester,  Clin.  Lecturer  Diseases  of  the  Heart, 
Dean  of  Clin.  Instruction,  University  of  Manchester. 
12mo,  Cloth,  2nd  Edition,  120  Pages,  Illustrated.  .$1.50  net. 

BEOWNE:  Eeligio  Medici,  Letters  to  a  Friend,  etc.,  and 
Christian  Morals.  2nd  Edition,  with  Preface  by  Drs.  Osier 
and  Packard In  Preparation. 

BEUCE:     Lectures  on  Tuberculosis  to  Nurses.    Based  on 
a   course   delivered   to   the   Queen   Victoria   Jubilee   Nurses. 
By  Olliver  Bruce,  M.R.c.s.,  l.r.c.p.,  Joint  Tuberculosis  Officer, 
County  of  Essex. 
12mo,  Cloth,  124  Pages,  Illustrated $1.00  net. 

BEUNTON:     Therapeutics    of   the    Circulation.    By   Sir 
Lauder     Brunton,     m.d.,     d.sc,    ll.d.    Edin.,    ll.d.    Aberd., 
f.r.c.p.,   f.r.s.     Consulting  Physician  to   St.   Bartholomew's 
Hospital.     Second  Edition,  Entirely  Eevised. 
Cloth,  xxiv-L.536  Pages,  110  Illustrations $2.50  net. 

BULKLEY:     Cancer:    Its  Cause  and  Treatment,  Volume 
I.     By  L.  Duncan  Bulkley. 
8vo,  Cloth,  224  Pages $1.50  net. 

BULKLEY  :  Cancer  :  Its  Cause  and  Treatment,  Volume  ii. 
By  L.  Duncan  Bulkley.    8vo,  Cloth,  272  Pages $1.50  net. 


BOEBEB'S  MEDICAL  MON OGB ABBS  3 

BULKLEY:  Compendium  of  Diseases  of  the  Skin.  Based 
on  an  analysis  of  thirty  thousand  consecutive  cases.  With 
a  Therapeutic  Formulary,  by  L.  Duncan  Bulkley,  a.m., 
m.d.  Physician  to  the  New  York  Skin  and  Cancer  Hospital; 
Consulting  Physician  to  the  New  York  Hospital. 
8vo,  Cloth,  xviii-f-286  Pages $2.00  net. 

BULKLEY:     Diet  and  Hygiene  in  Diseases  of  the  Skin. 
By  L.  Duncan  Bulkley. 
8vo,  Cloth,  xvi-j-194  Pages $2.00  net. 

BULKLEY:  The  Influence  of  the  Menstrual  Function 
on  Certain  Diseases  of  the  Skin.  By  L.  Duncar.  Bulkley. 
12mo,  Cloth,  108  Pages $1.00  net. 

BULKLEY:  Principles  and  Application  of  Local  Treat- 
ment in  Diseases  of  the  Skin.  By  L.  Duncan  Bulkley. 
12mo,  Cloth,  130  Pages $1.00  net. 

BULKLEY:     The  Eelations  of  Diseases  of  the  Skin  to 
Internal  Disorders  :  With  Observations  on  Diet,  Hygiene 
and  General  Therapeutics.     By  L.  Duncan  Bulkley. 
12mo,   Cloth,  175  Pages $1.50  net. 

CAEEEL  AND  DEHELLY:  The  Treatment  of  Infected 
Wounds.  By  A.  Carrel  and  G.  Dehelly.  Authorized  Transla- 
tion from  the  French  by  Herbert  Child,  m.d.,  Formerly  Sur- 
geon, French  Eed  Cross,  Capt.  r.a.m.c.  (Ty.),  with  an 
Introduction  by  Sir  Anthony  A.  Bowlby,  f.r.c.s.,  Temporary 
Surgeon  General,  Army  Medical  Service. 
12mo,  Cloth,  250  Pages,  97  Illustrations $2.00  net. 

CAUTLEY:     The  Diseases  of  Infants  and  Children.     By 
Edmund  Cautley,  m.d.  Cantab.,  f.r.c.p.  Lond.     Senior  Physi- 
cian to  the  Belgrave  Hospital  for  Children,  etc. 
Large  8vo,  Cloth,  1042  Pages $7.00  net. 

CLAEKE  :    Problems  in  the  Accommodation  and  Eefractton 
of  the  Eye,  a  Brief  Eeview  of  the  Work  of  Donders, 
and  the  Progress  Made  During  the  Last  Fifty  Years.  By 
Ernest   Clarke,    m.d.,   b.s.,    f.r.c.s. 
8vo,  Boards,  110  Pages $1.00  net. 

COOKE:     The  Position  of  the  X-Eays  in  the  Diagnosis 
and  Prognosis  of  Pulmonary  Tuberculosis.     By  W.  E. 
Cooke,  m.b.,  m.r.c.p.e.,  d.p.h.   (Lond.). 
8vo,  Cloth,  Illustrated $1.50  net. 

COOPEE:     Pathological    Inebriety.     Its    Causation    and 
Treatment.     By   J.  W.   Astley   Cooper.     Medical   Superin- 
tendent and  Licensee  of  Ghyllwood  Sanatorium.    With  Intro- 
duction by  Sir  David  Ferrier,  m.d.,  f.r.s. 
12mo,  Cloth,  xvi+151  Pages $1.50  net. 


4  HOEBEB'S  MEDICAL  MONOGBAPHS 

COOPER:    The   Sexual   Disabilities   of  Man,   and   Their 
Treatment.    By  Arthur  Cooper.    Consulting  Surgeon  to  the 
Westminster  General  Dispensary,   London. 
3rd  Edition,  12mo,  Cloth,  viii+227  Pages $2.50  net. 

COEBETT-SMITH:  The  Problem  op  the  Nations.  A  Study 
in  the  Causes,  Symptoms  and  Effects  of  Sexual  Disease,  and 
the  Education  of  the  Individual  Therein.  By  A.  Corbett- 
Smith,  Editor  of  The  Journal  of  State  Medicine;  Lec- 
turer in  Public  Health  Law  at  the  Eoyal  Institute  of  Public 
Health.    Large  8vo,  Cloth,  xii-f-107  Pages $1.00  net. 

COENET  :    Acute  General  Miliary  Tuberculosis.    By  Prof. 
Dr.  G.  Cornet,  Berlin.     Transi,  by  F.  S.  Tinker,  b.a.,  m.b. 
8vo,  Cloth,  viii-j-107  Pages, $1.50  net. 

CEOOKSHANK:     Flatulence  and  Shock.    By  F.  G.  Crook- 
shank,  m.d.  Lond.,  m.r.c.p.    Physician  (Out  Patients)  Hamp- 
stead  General  and  N.  W.  Lond.  Hospital. 
8vo,  Cloth,  iv-L.47  Pages $1.00  net. 

DAVIDSON:     Localization   by    X-Eays    and   Stereoscopy. 
By  Sir  James  Mackenzie  Davidson,  m.b.,  cm.  Aberd.     Con- 
sulting  Medical   Officer,   Eoentgen   Eay   Department,   Eoyal 
London  Ophthalmic  Hospital. 
8vo,  Cloth,  72  pp.,  Plates  and  58  Stereo.  Figs $3.00  net. 

DAWSON:     The  Causation  of  Sex  in  Man.    By  E.  Eumley 
Dawson,  l.r.c.p.  Lond.,   m.r.c.s.  England. 
8vo,  Cloth,  240  Pages,  with  21  Illustrations $3.00  net. 

DELOEME:  War  Surgery.  By  Edmond  Delorme,  General 
Medical  Inspector  of  the  French  Army.  Translated  by  D. 
De  Meric,  Surgeon  to  In-Patients,  French  Hospital,  London. 
12mo,  Cloth,  Illustrated,  248  Pages $1.50  net. 

EDEIDGE-GEEEN:     The  Hunterian  Lectures  on  Colour- 
Vision  and  Colour  Blindness.    Delivered  before  the  Eoyal 
College  of  Surgeons  of  England  on  February  1st  and  3rd, 
1911.     By  Professor  F.  W.  Edridge-Green,  m.d.,  f.r.c.s. 
8vo,  Cloth,  x-f-76  Pages $1.50  net. 

EHELICH:  Experimental  Eesearches  on  Specific  Thera- 
peutics. By  Prof.  Paul  Ehrlich,  m.d.,  d.sc.  Oxon.  The 
Harben  Lectures  for  1907  of  Eoyal  Institute  of  Public  Health. 
16mo,  Cloth,  x-f-95  Pages $1.00  net. 

EINHOEN:      Lectures    on    Dietetics.     By    Max    Einhorn, 
Professor  of  Medicine  at  N.  Y.  Post-Graduate  Med.  School 
and  Hospital,  Visit.  Phys.  German  Hospital,  N.  Y. 
12mo,  Cloth,  xvi+156  Pages $1.25  net. 

ELLIOT  :  Glaucoma.  By  Col.  Eobert  Henry  Elliot,  m.d.,  f.r.c.s. 
8vo,  Cloth,  60  Pages,  with  23  Illustrations $1.50  net. 


EOEBEB'S  MEDICAL  MONOGRAPHS 


ELLIOT:  Sclero-Corneal  Trephining  in  the  Operative 
Treatment  of  Glaucoma,,  By  Kobert  Henry  Elliot,  m.d., 
b.s.  Lond.,  d.sc.  Edin.,  f.r.c.s.  Eng.  Lieut.  Colonel  i.m.s. 
2d  Ed.     8vo,  Cloth,  135  Pages,  33  Illus $3.00  net. 

EMEEY  :  Immunity  and  Specific  Therapy.  By  Wm.  D 'Este 
Emery,  m.d.,  b.sc.  Lond.  Clinical  Pathologist  to  King's 
College  Hospital  and  Pathologist  to  the  Children's  Hospital. 
8vo,  Cloth,  448  Pages,  with  2  Illustrations $3.50  net. 

ADOPTED  BY  THE  U.   S.  ARMY. 

FAILLA,  JANEWAY  AND  BABEINGEB  :  Radium  Therapy 
in  Cancer  at  the  Memorial  Hospital.  (See  Janeway,  Bar- 
ringer  and  Failla.) 

FISHBERG:     The  Internal  Secretions.     (See  Gley.) 

FBIESNEB  AND  BEAUN:  Cerebellar  Abscess;  Its  Eti- 
ology, Pathology,  Diagnosis  and  Treatment.  By  Isidore 
Friesner,  m.d.,  f.a.c.s.,  Adjunct  Professor  of  Otology  and 
Assistant  Aural  Surgeon,  Manhattan  Eye,  Ear  and  Throat 
Hospital  and  Post-Graduate  Medical  School,  and  Alfred 
Braun,  m.d.,  f.a.c.s.,  Assistant  Aural  Surgeon,  Manhattan 
Eye,  Ear  and  Throat  Hospital,  Adjunct  Professor  of 
Laryngology,  New  York  Polyclinic  Hospital  and  Medical 
School  and  Adjunct  Otologist,  Mt.  Sinai  Hospital. 
8vo,  Cloth,  186  Pages,  10  Plates,  16  Illus $2.50  net. 

GEESTEE:     Eecollections  of  a  New  York  Surgeon.     By 
Arpad  G.  Gerster,  m.d. 
8vo,  Cloth,  about  375  Pages,  Illustrated $3.50  net. 

GHON:     The    Primary   Lung   Focus  -  of    Tuberculosis   in 
Children.     By  Anton   Ghon,   m.d.,   English   Translation  by 
D.  Barty  King,  m.a.,  m.d.  Edin.,  m.r.c.p. 
Large  8vo,  Cloth,  196  pp.,  72  Illus.,  2  Plates $3.75  net. 

GILES:     Anatomy  and  Physiology  of  the  Female  Genera- 
tive Organs  and  of  Pregnancy.    By  Arthur  E.  Giles,  m.d., 
b.sc.  Lond.,  m.r.c.p.  Lond.;  f.r.c.s.  Ed.    Gynecologist  to  the 
Prince  of  Wales  General  Hospital. 
Large  8vo,  24  Pages,  with  Mannikin $1.50  net. 

GLEY:    The  Internal  Secretions.    By  E.  Gley,  m.d.    Mem- 
ber  of   the   Academy   of    Medicine   of   Paris,   Professor   of 
Physiology  in  the  College  of  France,  etc.     Authorized  Trans- 
lation, Translated  and  Edited  by  Maurice  Fishberg,  m.d. 
8vo,  Cloth,  241  Pages $2.00  net. 

GOULSTON:  Cane  Sugar  and  Heart  Disease.  By  Arthur 
Goulston,  m.a.,  m.d.  Cantab.  Hunterian  Society's  Medallist, 
1912.    8vo,  Cloth,  107  Pages $2.00  net. 


6  HOEBER'S  MEDICAL  MONOGRAPHS 

GEEEFF:  Guide  to  the  Microscopic  Examination  of  the 
Eye.  By  Professor  E.  Greeff.  Director  of  the  University 
Ophthalmic  Clinique  in  the  Eoyal  Charity  Hospital,  Berlin. 
With  the  co-operation  of  Professor  Stock  and  Professor 
Wintersteiner.  Translated  from  the  third  German  Edition 
by  Hugh  Walker,  m.d.,  m.b.,  cm. 
Large  Svo,  Cloth,  86  Pages,  Illustrated $2.00  net. 

HAEEIS:     Lectures   on   Medical  Electricity  to   Nurses. 
An  Illustrated  Manual  by  J.  Delpratt  Harris,  m.d.,  m.r.c.s. 
12mo,  Cloth,  88  Pages,  illustrated $1.00  net. 

HELLMAN:  Amnesia  and  Analgesia  in  Parturition — 
Twilight  Sleep.  By  Alfred  M.  Hellman,  b.a.,  m.d.,  f.a.c.s. 
8vo,  Cloth,  with  Charts,  200  Pages $1.50  net. 

HEWATT:     The   Examination    of   the    Urine,    and    Other 
Clinical  Side  Eoom  Methods.     By  Andrew  Fergus  Hewatt, 
m.b.,  ch.b.,  m.r.c.p.  Edin. 
16mo,  5th  Edition,  Numerous  Illustrations $1.00  net. 

HOFMANN-GAESON  :  Eemedial  Gymnastics  for  Heart 
Affections.  Used  at  Bad-Nauheim.  Being  a  Translation 
of  "Die  Gymnastik  der  Herzleidenden ' '  von  Dr.  Med.  Julius 
Hofmann  und  Dr.  Med.  Ludwig  Pohlman.  Berlin  and  Bad- 
Nauheim.  By  John  George  Garson,  m.d.  Edin.,  etc.  Physi- 
cian to  the  Sanatoria  and  Bad-Nauheim,  Eversley,  Hants. 
Large  8vo,  Cloth,  144  Pages,  51  Full-page  Illus $2.00  net. 

HOWAED:     The  Therapeutic  Value  of  the  Potato.     By 
Heaton  C.  Howard,  l.r.c.p.  Lond.,   m.r.c.s.  Eng. 
8vo,  Paper,   vi-{-31  Pages,   Illustrated 50c 

JANEWAY,  BAEEINGEE  AND  FAILA:  Eadium  Therapy 
in  Cancer  at  the  Memorial  Hospital,  Eeport  of  1915-1916. 
By  Henry  H.  Janeway,  m.d.,  with  the  Discussion  of  the 
Treatment  of  Cancer  of  the  Prostate  and  Bladder  by  Ben- 
jamin S.  Barringer,  m.d.,  and  an  Introduction  upon  the 
Physics  of  Eadium  by  G.  Failla. 
8vo,  Cloth,  about  225  Pages In  Press. 

JELLETT:  A  Short  Practice  of  Midwifery  for  Nurses. 
Embodying  the  treatment  adopted  in  the  Eotunda  Hospital, 
Dublin.  By  Henry  Jellett,  b.a.,  m.d.  (Dublin  University), 
f.r.c.p.i.,  Master  Eotunda  Hospital.  With  Six  Plates  and 
169  Illustrations  in  the  Text,  also  an  Appendix,  a  Glossary 
of  Medical  Terms,  and  the  Eegulations  of  the  Central  Mid- 
wives  Board. 
12mo,  Cloth,  xvi+508  Pages $2.50  net. 


HOEBEB'S  MEDICAL  MON  OGB  ABB  S  7 

JONES:     Notes  on  Military  Orthopaedics.    By  Col.  Kobert 
Jones,  C.B.,  Inspector  of  Military  Orthopaedics,  Army  Med- 
ical Service. 
8vo,  Cloth,  132  Pages,  95  Illustrations $1.50  net. 

KENWOOD:  Public  Health  Laboratory  Work.  By  Henry 
B.  Kenwood,  m.b.,  f.r.s.  Edin.,  p.p.h.,  f.c.s.,  Chadwick 
Prof,  of  Hygiene  and  Public  Health,  University  of  London. 
6th  Edition,  8vo,  Cloth,  418  Pages,  Illustrated $4.00  net. 

KERLEY:     What  Every  Mother  Should  Know  About  Her 
Infants  and  Young  Children.    By  Charles  Gilmore  Kerley, 
m.d.     Professor  of  Diseases   of   Children,  N.  Y.  Polyclinic 
Medical    School    and    Hospital. 
8vo,  Paper,  107  Pages 35e  net. 

KETTLE:     The  Pathology  of  Tumors.     By  E.  H.  Kettle, 
M.D.,  b.s.,  Assistant  Pathologist,  St.  Mary's  Hospital,  and 
Assistant  Lecturer  on  Pathology,  St.  Mary's  Hospital. 
8vo,  Cloth,  242  Pages,  126  Illustrations $3.00  net. 

LEWERS:  A  Practical  Textbook  of  the  Diseases  of 
Women.  By  Arthur  H.  N.  Lewers,  m.d.  Lond.  Senior 
Obstetric  Physician,  London  Hospital. 

With  258  Illustrations,  13  Colored  Plates,  5  Plates  in  Black 
and  White.   7th  Ed.,  8vo,  Cloth,  xii+540  Pages $4.00  net. 

LEWIS:     Clinical  Disorders  of  the  Heart  Beat.    A  Hand- 
book for  Practitioners  and  Students.    By  Thomas  Lewis,  m.d., 
d.sc,  f.r.c.p.     Assistant  Physician  and  Lecturer  in  Cardiac 
Pathology,  University  College  Hospital  Medical  School. 
3rd  Ed.,  8vo,  Cloth,  116  Pages,  54  Illustrations.  .$2.00  net. 

LEWIS:     Lectures  on  the  Heart.     Comprising  the  Herter 
Lectures   (Baltimore),  a  Harvey  Lecture    (New  York),  and 
an  Address  to  the  Faculty  of  Medicine  at  McGill  University 
(Montreal).     By  Thomas  Lewis. 
124  Pages,  with  83  Illustrations $2.00  net. 

LEWIS  :  Clinical  Electrocardiography.  By  Thomas  Lewis. 
8vo,  Cloth,  120   Pages,  with  Charts $2.00  net. 

LEWIS  :  The  Mechanism  of  the  Heart  Beat.  With  Special 
Reference  to  Its  Clinical  Pathology.  By  Thomas  Lewis. 
Large  8vo,  Cloth,  295  Pages,  227  Tllus $7.00  net. 

McCLURE:  A  Handbook  of  Fevers.  By  J.  Campbell  Mc- 
Clure,  m.d.,  Glasgow.  Physician  to  Out-Patients,  The 
French  Hospital,  and  Physician  to  the  Margaret  Street 
Hospital  for  Consumption  and  Diseases  of  the  Chest,  London. 
8vo,  Cloth,  470  Pages,  with  Charts $3.50  net. 


8  HOEBEB'S  MEDICAL  MONOGBAPES 

McCETTDDEN:    The  Chemistry,  Physiology  and  Pathology 
of  Uric  Acid,  and  the  Physiologically  Important  Purin 
Bodies.    With  a  Discussion  of  the  Metabolism  in  Gout.     By 
Francis   H.    McCrudden. 
12mo,  Paper,  318  Pages $2.00  net. 

McKISACK:    Systematic  Case  Taking.     A  Practical  Guide 
to  the  Examination  and  Eecording  of  Medical  Cases.     By 
Henry  Lawrence  McKisack,  m.d.,  m.r.c.p.  Lond. 
12mo,  Cloth,  166  Pages $1.50  net. 

MACKENZIE:     Symptoms  and  Their  Interpretations.    By 
James  Mackenzie,  m.d.,  ll.d.  Aber.  and  Edin. 
8vo,  Cloth,  Illustrated,  xxii-|-304  Pages $3.00  net. 

MACMICHAEL:  The  Gold-Headed  Cane.  By  William  Mac- 
michael.  Eeprinted  from  the  2nd  Edition.  With  a  Preface 
by  Sir  William  Osier  and  an  Introduction  by  Dr.  Francis  B. 
Packard.  Printed  from  large  Scotch  type  on  a  special  heavy- 
weight paper,  5V4  by  7%  inches,  bound  in  blue  Italian  hand- 
made paper,  with  parchment  back,  gilt  top,  square  back, 
and  gold  stamping  on  back  and  side $3.00  net. 

MAGILL:     Notes  on  Galvanism  and  Faradism.     By  E.  M. 
Magill,  m.b.,  b.s.  Lond.,  r.c.s.i.   (Hons.) 
12mo,  Cloth,   220  Pages,   67   Illustrations $1.50  net. 

MAETINDALE    and    WESTCOTT:     <  '  Salvarsan  '  '    "606" 
(Dioxy-Diamino-Arsenobenzol),  Its  Chemistry,  Pharmacy 
and  Therapeutics.    By  W.  Harrison  Martindale,  ph.d.  Mar- 
burg,  f.c.s.,  and  W.  Wynn  Westcott,  m.b. 
8vo,  Cloth,  xvi-L.76  Pages $1.50  net. 

MINETT  :    Diagnosis  of  Bacteria  and  Blood  Parasites.    By 

E.  P.   Minett,   m.d.,   d.p.h.,  d.t.m.   and  h.,   m.r.c.s.,  l.r.c.p. 
12mo,  Cloth,  viii-r-80  Pages $1.00  net. 

MOTT  :    Nature  and  Nurture  in  Mental  Development.    By 

F.  W.  Mott,  m.d.,  f.r.s.,  f.r.c.p.    Pathologist  to  the  London 
County  Asylums. 

12mo,   Cloth,   151   Pages,  with  Diagrams $1.50   net. 

MUEBELL:     What  To  Do  in  Cases  of  Poisoning.    By  Wil- 
liam Murrell,   m.d.,  f.r.c.p.     Senior  Physician  to  the  West- 
minster Hospital. 
11th  Edition,  16mo,  Cloth,  283  Pages $1.00  net. 

OLIVEE:  Lead  Poisoning:  From  the  Industrial,  Medical 
and  Social  Point  of  View.  Lectures  Delivered  at  Eoyal  Insti- 
tute of  Public  Health.  By  Sir  Thomas  Oliver,  m.a.,  m.d.,  f.r.c.p. 
12mo,  Cloth,  294  Pages $2.00  net. 


HOEBEB'S  MEDICAL  MONOGBAPES  9 

OSLEE:  Two  Essays.  By  Sir  William  Osier,  m.d.  Regius 
Professor  of  Medicine  at  Oxford. 

Vol.  1.  A  Way  of  Life.  An  Address  to  Yale  Students, 
Sunday  Evening,  April  20th,  1913.  16mo,  Cloth,  61 
Pages 50c  net. 

Vol.  2.  Man's  Redemption  of  Man.  A  Lay  Sermon, 
McEwan   Hall,   Edinburgh,   Sunday,   July  2d,   1910.      16mo, 

Cloth,  63  Pages 50c  net. 

The  Set  Neatly  Bound  and  Boxed $1.00  net. 

(A  handsome  presentation  set.) 

OTT:     Fever,  Its  Thermotaxis  and  Metabolism.    By  Isaac 

Ott,    A.M.,    M.B. 

12mo,  Cloth,  168  Pages,  Illustrated $1.50  net. 

PAGET:     For  and  Against  Experiments  on  Animals.    Evi- 
dence   before    the    Royal    Commission    of    Vivisection.      By 
Stephen  Paget,  f.r.c.s.     With  an  Introduction  by  The  Right 
Hon.  The  Earl  of  Cromer. 
8vo,  Cloth,  Illustrated,  xii-}-344  Pages $1.50  net. 

PEGLER:  Map  Scheme  of  the  Sensory  Distribution  of 
the  Fifth  Nerve  (Trigeminus)  with  Its  Ganglia  and 
Connections.  By  L.  Hemington  Pegler,  m.d.,  m.r.c.s.  Senior 
Surgeon,  Metropolitan  Ear,  Nose  and  Throat  Hospital,  etc. 

Mounted  on  Rollers,  4ft.  1  in.  x.  4  ft.  8  in $7.00  net. 

Folded  in  Cloth  Binder $8.00  net. 

RAWLING:     Landmarks   and   Surface   Markings   of   the 
Human  Body.    By  L.  Bathe  Rawling,  m.b.,  b.c.,  f.r.c.s. 
5th  Ed.,  8vo,  Cloth,  31  Plates,  xii-f-96  Pages  of  Text.  $2.00  net. 

REPORT  OF  RADIUM  THERAPY  IN  CANCER  AT  THE 
MEMORIAL  HOSPITAL.  (See  Janeway,  Barringer  and 
Failla.) 

RITCHIE  :  Auricular  Flutter.  By  William  Thomas  Ritchie, 
m.d.,  f.r.c.p.e.,  f.r.s.e.  Physician  to  the  Royal  Infirmary. 
Large  8vo,  Cloth,  156  Pages,  21  Plates,  107  Illus.  .$3.50  net. 

RUTHERFORD  :  The  Ileo-Oecal  Valve.  By  A.  H.  Ruther- 
ford, m.d.  Edin.  8vo,  Cloth,  63  Pages  of  Text,  23  Full  Page 
Plates,  3  of  Which  Are  Colored $2.25  net. 

SAALFELD  :  Lectures  on  Cosmetic  Treatment.  A  Manual 
for  Practitioners.  By  Dr.  Edmund  Saalfeld  of  Berlin. 
Translated  by  J.  F.  Dally,  m.a.,  m.d.,  b.c.  Cantab., 
m.r.c.f.  Lond.  With  an  Introduction  and  Notes  by  P.  S. 
Abraham,  m.a.,  m.d.,  b.sc,  f.r.c.s.i. 
12mo,  Cloth,  xii-j-186  Pages,  Illustrated $1.75  net. 


10  HOEBEB'S  MEDICAL  MONOGRAPHS  ' 

SCHMITT  :  Studies  in  the  Anatomy  and  Surgery  of  the 
Nose  and  Ear.  By  A.  Einil  Sclimitt,  m.d.,  Past  Chief  Med- 
ical and  Sanitary  Officer,  Nile  Keservoir  Works,  Assuan, 
Egypt;  Past  Instructor  in  Operative  Surgery,  College  of 
Physicians  and  Surgeons,  and  Past  Attending  Surgeon,  Ger- 
man Hospital,  o.p.d.,  New  York. 
Large  Svo,  Cloth,  16S  pages,  45  Plates In  Press. 

SCHOOL  OF  SALEKNUM,  THE,  Including  Regimen  Sani- 
tatis  Salernitatum,  and  Sir  John  Harrington's  English  Ver- 
sion, with  an  Introduction  by  Francis  R.  Packard,  m.d.,  and 
a  Note  on  the  Prehistory  of  the  Regimen  Sanitatis  by  Field- 
ing H.  Garrison,  m.d.     Illustrated In  Press. 

SCOTT  :  Modern  Medicine  and  Some  Modern  Remedies.  By 
Thomas  Bodley  Scott,  with  a  Preface  by  Sir  Lauder  Brunton. 
12mo,  Cloth,  xv+159  pages $1.50  net. 

SCOTT:     The  Road   to   a   Healthy   Old  Age.     Essays  by 
Thomas  Bodley  Scott,  m.d. 
12mo,  Cloth,  104  Pages $1.00  net. 

SENATOR  and  KAMINER:  Marriage  and  Disease.  Being 
an  Abridged  Edition  of  "  Health  and  Disease  in  Relation  to 
Marriage  and  the  Married  State."  By  Prof.  H.  Senator  and 
Dr.  S.  Kaminer.  Trans,  from  the  German  by  J.  Dulberg,  m.d. 
8vo,  Cloth,  452  Pages $2.50  net. 

SMITH:     Some  Common  Remedies,  and  Their  Use  in  Prac- 
tice.    By  Eustace  Smith,  m.d. 
12mo,  Cloth,  viii+H2  Pages $1.25  net. 

SQUIER   and  BUGBEE:     Manual  of  Cystoscopy.     By   J. 
Bently  Squier,   m.d.     Professor  of   Genito- Urinary  Surgery, 
New  York  Post-Graduate  Medical  School  and  Hospital,  and 
Henry  G.  Bugbee,  m.d. 
8vo,  Flex.  Leather,  xiv+117  Pages,  26  Colored  Plates  $3.00  net. 

ADOPTED   BY   THE   U.    S.   ARMY. 

STARK:  The  Growth  and  Development  of  the  Baby.  A 
tabular  chart,  giving  the  result  of  personal  observation,  veri- 
fied by  authoritative  data,  as  to  development,  weight,  height, 
etc.,  during  the  first  seven  years.  By  Morris  Stark,  m.a.,  b.s., 
m.d.  Instructor  of  Pediatrics,  N.  Y.  Post-Graduate  Med.  Sch. 
Heavy  Paper,  20  by  25  inches 50c  net. 

STEPHENSON:     Eye-Strain  in   Every-day  Practice.     By 
Sidney  Stephenson,  m.b.,  cm.  Edin.,  d.o.  Oxon.,  f.r.c.s.  Edin< 
Editor  of  the  Ophthalmoscope. 
8vo,  Cloth,  x+139  Pages $1.50  net. 


HOEBEB'S  MEDICAL  MONOGBAPES  11 

STEPHENSON:     A   Review   of   Hormone   Therapy.     1913. 

8vo,  Cloth,  viii+170  Pages $1.00  net. 

Bound   and   interleaved    edition    of   the   famous   "  Hormone 

Number"  of  the  Prescriber   (Edinburgh). 

SWIETOCHOWSKI  :      Mechano-Therapeutics    in    General 
Practice.    By  G.  de  Swietochowski,  m.d.,  m.r.c.s.    Fellow  of 
the  Royal  Society  of  Medicine;  Clinical  Assistant,  Electrical 
and  Massage  Department,  King's  College  Hosp. 
12mo,  Cloth,  xiv+141  Pages,  31  Illustrations $1.50  net. 

TOUSEY:  Roentgenographs  Diagnosis  of  Dental  Infec- 
tion in  Systemic  Diseases.  By  Sinclair  Tousey,  a.m.,  m.d. 
8vo,  Cloth,  75  Pages  and  64  Illus $1.50  net. 

TRUESDELL:  Birth  Fractures  and  Epiphyseal  Disloca- 
tions. By  Edward  D.  Truesdell,  m.d.,  Assistant  Attending 
Surgeon  and  Roentgenologist,  Lying-in  Hospital,  Associate 
Surgeon,  St.  Mary's  Free  Hospital  for  Children,  New  York. 
Large  8vo,  Cloth,  128  Pages,  143  Illustrations In  Press. 

TURNER  and  PORTER:  The  Skiagraphy  of  the  Acces- 
sory Nasal  Sinuses.  By  A.  Logan  Turner,  m.d.,  f.r.c.s.b., 
f.r.s.e.  Surgeon  to  the  Ear  and  Throat  Department,  the 
Royal  Infirmary,  Edinburgh,  and  W.  G.  Porter,  m.b.,  b.sc, 
f.r.c.s.e.  Surgeon  to  Eye  and  Throat  Infirmary,  Edinburgh. 
Quarto,  Cloth,  45  Pages  of  Text,  39  Plates $5.00  net 

von    RUCK    and    von    RUCK:     Studies    in    Immunization 
against    Tuberculosis.      By    Karl    von    Ruck,    m.d.,    and 
Silvio  von  Ruck,  m.d. 
8vo,  Cloth,  xvi+439  Pages $4.00  net. 

WANKLYN:  How  to  Diagnose  Smallpox.  A  Guide  for 
General  Practitioners,  Post-Graduate  Students,  and  Others. 
By  W.  McC.  Wanklyn,  b.a.  Cantab.,  m.r.c.s.,  l.r.c.p.,  d.p.h. 
8vo,  Cloth,  102  Pages,  Illustrated $1.50  net. 

WATSON:  Gonorrhoea  and  Its  Complications  in  the  Male 
and  Female.  By  David  Watson,  m.b.,  cm.,  Surgeon,  Glasgow 
Lock  Hospital  Dispensary,  Surgeon  for  Venereal  Diseases, 
Glasgow  Royal  Infirmary,  etc.,  etc. 

8vo,  Cloth,  375  Pages,  72  Illustrations,  12  Plates,  Some  Col- 
ored  $3.75  net. 

WHITE  :     The  Pathology  of  Growth.  Tumours.  By  Charles 
Powell    White,    m.c,    f.r.c.s.      Director,    Pilkington    Cancer 
Research  Fund,  Pathologist  Christie  Hospital,  Special  Lec- 
turer in  Pathology,  University  of  Manchester. 
8vo,  Cloth,  xvi-j-235  Pages,  Illustrated $3.50  net. 


12  HOEBER'S  MEDICAL  MONOGBAPHS 

WHITE:  Occupational  Affections  of  the  Skin.  A  brief 
account  of  the  trade  Processes  and  Agents  which  give  rise 
to  them.  By  P.  Prosser  White,  m.d.  Ed.,  M.R.c.s.  Lond.  Life 
Vice-President,  Senior  Physician  and  Dermatologist,  Boyal 
Albert  Edward  Infirmary. 
8vo,  Cloth,  165  Pages $2.00  net. 

WICKHAM  and  DEGKAIS:  Radium.  As  employed  in  the 
treatment  of  Cancer,  Angiomata,  Keloids,  Local  Tuberculosis 
and  other  affections.  By  Louis  Wickham,  m.v.o.  Médecin 
de  St.  Lazare;  Ex-Chef  de  Clinique  à  L'Hôpital  St. 
Louis,  and  Paul  Degrais,  Ex-Chef  de  Laboratoire  à  L'Hôpital 
St.  Louis. 
8vo,  Cloth,  53  Illustrations,  viii-f-111  Pages $1.25  net. 

WEENCH:     The  Healthy  Marriage.    A  Medical  and  Psycho- 
logical Guide  for  Wives.    By  G.  T.  Wrench,  M.D.,  b.s.  Lond.,  ♦ 
Past  Assistant  Master  of  the  Rotunda  Hospital,  Dublin. 
2nd  Edition,  8vo,  Cloth,  viii+300  Pages $1.50  net. 

WEIGHT:    The  Unexpurgated  Case  against  Woman  Suf- 
frage.    By  Sir  Almroth  E.  Wright,  m.d.,  f.r.s. 
8vo,  Cloth,  xii-fl88  Pages $1.00  net. 

WEIGHT:     On  Pharmaco-Therapy  and  Preventive  Inocu- 
lation; Applied  to  Pneumonia  in  the  African  Native,  with 
a   Discourse   on   the   Logical   Methods   Which   Ought  to   Be  / 
Employed   in   the   Evaluation   of   Therapeutic   Agents.     By 
Sir  Almroth  E.  Wright,  M.D.,  F.R.S. 
8vo,  Cloth,  124  Pages.... ...$2.00  net. 

YOUNG:  The  Mentally  Defective  Child.  By  Meredith 
Young,  m.d.,  d.p.h.,  d.s.sc,  Chief  School  Medical  Officer, 
Cheshire  Education  Committee;  Lecturer  in  School  Hygiene, 
Victoria  University  of  Manchester;  Certifying  Medical  Offi- 
cer to  Local  Authority  (Mental  Deficiency  Act),  Co.  Cheshire. 
12mo,  Cloth,  xi+140  Pages.     Illustrated $1.50  net. 

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